An interesting and thought-provoking study, even with its flaws.

The authors concluded that system changes surrounding anaesthetic drug delivery reduce medication error.

A ‘care bundle’ approach was taken to improve drug safety through system design and human factors considerations:

• Coloured drug labels with barcodes.
• Computerised drug crosscheck.
• Computerised allergy and drug expiration alerts.
• Re-organised anaesthesia workplace, focusing on the drug administration workflow.
• Prefilled syringes for: calcium chloride, ephredrine, fentanyl, lidocaine, magnesium sulphate, metaraminol, midazolam, neostigmine, and pancuronium.
• Automated computerised anaesthetic record.

But the problems...

No randomisation, no blinding, observational study, completely voluntary use of the safety system and self-reporting of errors...

Were the improvements due to the intervention, or simply a greater interest and priority given to anaesthetic safety? (Would it matter?)

In only 15% of anaesthetics was the new system (voluntarily) used, and thus may represent anaesthetists more motivated to prioritise medication safety over convenience or convention.

Finally error is being used (not unreasonably) as a surrogate marker for patient harm. (Although the authors did try to sneak in... “a non-significant reduction (p=0.055) in the harm attributable to drug administration error” 🙄)

Final word of caution

Even this quite impressive system was not immune to error. There were 19 cases of violation of the video and/or audio crosscheck before drug administration. Automated safety systems are obviously no panacea.

Additionally, although there was an observed reduction in all drug errors, there was no reduction specifically in drug substitution error.

Nonetheless a refreshing and novel approach to anaesthetic drug safety, beyond the typical admonishment to just be safer.

More on the system used:

• Webster (2001): The frequency and nature of drug administration error during anaesthesia
• Merry (2001): A new, safety-oriented, integrated drug administration and automated anesthesia record system
• Webster (2004): A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods.

summary

• C S Webster, L Larsson, C M Frampton, J Weller, A McKenzie, D Cumin, and Alan F Merry.
• Centre for Medical and Health Sciences Education, Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
• Anaesthesia. 2010 May 1;65(5):490-9.

AbstractA safety-orientated system of delivering parenteral anaesthetic drugs was assessed in a prospective incident monitoring study at two hospitals. Anaesthetists completed an incident form for every anaesthetic, indicating if an incident occurred. Case mix data were collected and the number of drug administrations made during procedures estimated. From February 1998 at Hospital A and from June 1999 at Hospital B, until November 2003, 74,478 anaesthetics were included, for which 59,273 incident forms were returned (a 79.6% response rate). Fewer parenteral drug errors occurred with the new system than with conventional methods (58 errors in an estimated 183,852 drug administrations (0.032%, 95% CI 0.024-0.041%) vs 268 in 550,105 (0.049%, 95% CI 0.043-0.055%) respectively, p = 0.002), a relative reduction of 35% (difference 0.017%, 95% CI 0.006-0.028%). No major adverse outcomes from these errors were reported with the new system while 11 (0.002%) were reported with conventional methods (p = 0.055). We conclude that targeted system re-design can reduce medical error.

18 keywords...

hide…