• P C Gordon, R L Llewellyn, and M F M James.
• Department of Anaesthesia, Groote Schuur Hospital and University of Cape Town. gordon@cormack.uct.ac.za
• S. Afr. Med. J. 2006 Jul 1;96(7):630-2.

ObjectivesTo investigate the incidence, nature of and factors contributing towards wrong drug administrations by South African anaesthetists.DesignA confidential, self-reporting survey was sent out to the 720 anaesthetists on the database of the South African Society of Anaesthesiologists.ResultsA total of 133 questionnaires were returned for analysis (18.5% response rate). Of the respondents, 125 (94%) admitted to having inadvertently administered a wrong drug. Thirty respondents (22.6%) said they had made errors on at least four occasions. A total of 303 specific wrong drug administrations were described. Nearly 50% involved muscle relaxants. A further 43 incidents (14%) involved the erroneous administration of vasoactive drugs. Five deaths and 3 nonfatal cardiac arrests were reported. In 9.9% of incidents the anaesthetic time was prolonged by more than 30 minutes. Contributory causes identified included syringe swaps (40%), misidentification of drugs (27.1%), fatigue (14.1%), distractions (4.7%), and mislabelling of syringes (4.7%). Only 19% of respondents regularly use colour-coded syringe labels complying with the national standard.ConclusionsMost anaesthetists experienced at least one drug error. The incidence of wrong drug administrations by South African anaesthetists appears to be similar to that in Australasia and Canada. The commonest error was a 'syringe swap' involving muscle relaxants. Most drug errors are inconsequential. An important minority of incidents result in severe morbidity or death. The study supports efforts to improve ampoule labelling, to encourage the use of syringe labels based on the international colour code and to develop a national reporting system for such incidents.

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