Preventing Drug Administration Error During Anaesthesia

This presentation discusses the causes, kinds, and results of medication errors during anaesthesia and strategies to prevent them. It covers topics such as vulnerable system syndrome, five rights in medication administration, and recommendations from AAGBI, WHO, and the Royal College of Anaesthetists. The presentation emphasizes the importance of standardization, thorough checking of equipment, and vigilance during drug administration.

PREVENTING DRUG ADMINISTRATION ERROR DURING ANAESTHESIA
Name of the student
Name of the University
Author note

Medication Errors
occur in the case of:
Failure of process of
treatment
Harming the patient

Kinds of Medication
Error
Active failure
Latent Condition

Causes of Medication Errors
Inadequate experience of staff
Unfamiliarity with equipment
Carelessness
Lack of staff
Poor communication
Fatigue

Drugs involved in the
medication errors
Pentothel Sodium
Narcotic
Anticholinergics

Results of Medication Errors
Harm the health of that of the patient
Family loses confidence in the health care
organisation
The bad memories can haunt the patient

Prevention of the medical errors in Anaesthesia
Accidents of
medication error not
reported owing to
Fear of being
blamed of
carelessness( Schiff
et al. 2015).
One will be deemed
as forgetful

Strategies for preventing drug
administration error in
operation room
Reduction of complex system to a
simple form that can help in
enhancing the factor of safety
(Koutkias et al. 2014)
Standardisation can be a basic
principle that can help in
designing a safe system
Thorough checking of that of the
ampoules and that of equipments
before the starting of the
procedure.
Vigilance during administration
of drug can be of great help

The following strategies can play a pivotal role
in preventing medication errors (Wittich,
Burkle and Lanier 2014):
1.The label on that of the drug ampoule should
be read carefully before the injection of a drug
2.The contents of the labels on that of ampoules
along with that of syringes should be properly
optimized on the basis of agreed standard
pertaining to font, size and information
(Hutchinson et al. 2015).
3.The labelling of the syringes is an absolute
necessity

4.Formal organisation in relation to the drug
drawers along with that of work space should
be given proper attention to in terms of tidiness
5.Dangerous drugs should be removed from that
of the operation system
6.The labels should be given proper attention to
and checked by taking recourse to a second
person or a device like that of bar code reader
7.The errors made during administration should
be subject to the process of reviewing

Five rights in relation to Medication
Administration are:
Right Patient
Right Medication
Right Dose
Right Time
Right Route

Vulnerable System Syndrome:-
Organizational pathologies is responsible for
making each system prone to the errors
Tendency of blaming front line workers
Denying the existence of problematic
conditions

There are other measures that
can help in promoting safe drug
administration in relation to
anaesthesia (Hammerling 2015).
The labels should be done in a manner that is
standardized that emphasizes on the class along with
generic name in relation to each drug
The label should contain the bar code and colour code
that is class specific on the basis of the international
standard
Bar code reader can help in the scanning of the drug
during times of administration before it is linked to that
of auditory prompt that can help in the checking of the
drug identity
The scanned information should be integrated into that
of an automatic anaesthesia record that can significantly
reduce the cognitive load on that of the anaesthetist.

According to Smith et al. (2014),
devices should be used during
point of care that can
automatically measure dose of
that of the administered drug
Dosing nomograph on that of the
infusion syringe label can help in
avoiding the need of that of look-
up tables
The medication dispensing
system should have features like
that of single issue drawer along
with that of bar code scanner
that can facilitate the process of
safe dispensation of that of the
drugs

According to Rinke et al. (2014),
there are Six strategies that can
help in preventing errors in the
ICU. Some of them are as follows:
Elimination of extended work
schedule of that of the physicians
The physician order entry should
be computerised
Implementation of the support
system in relation to that of the
clinical decisions
The intravenous devices should be
computerised
The pharmacists should actively
participate in that of the ICU
Reconciliation in relation to
medication should be done

Recommendations of AAGBI
Policy documents have
been implemented by
that of AAGBI
Local scrutiny of the
practices
Local ownership of that
of the protocols
Drugs presented within
that of pre-filled syringes
The labelling of drugs
carried out by the
anaesthetist

Recommendations of WHO
Medication reviews
and Reconciliation
Automated
information system
Education
Multi-component
intervention

Recommendations of Royal Challenge of Anaesthetists
Patient Information-
 Consistent documentation
 Adding prompts to that of
preadmission card
Communication of drug
errors along with
information
• Elimination of usage of
dangerous abbreviation
• Incorporation of
computerised physician order
entry into that of the
strategic planning
Drug Labelling, nomenclature
and packaging
Enhancing the mechanism of
communication
Standardisation of the
anaesthetic cart tray and
consideration of the usage
pattern
Drug standardisation,
distribution and that of
storage
Evaluation of the needs and
segregation of the hazardous
products
Increasing the provision of that
of premixed solutions

Environment along with
workflow-
Minimizing the advance
preparation of that of drug
syringe
Returning or removing the
unused medication from that
of the work cart
Staff competency along with
education
Investigating and educating
the staff regarding the
dangers that is associated with
that of work around practice
Patient Education
Providing enhanced material
for that of preoperative
patient
Consideration of the
pharmacy involvement in the
case of same day assessment
Quality Process along with
risk management
Encouraging the reporting of
all the practitioners
Consideration of the
monitoring use of all the
trigger drugs

References:
Aagbi.org (2018). AAGBI. [online] Aagbi.org. Available at: https://www.aagbi.org/
[Accessed 19 Feb. 2018].
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audit with feedback knowledge translation intervention to promote medication error
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Deichsel, E.L. and Shekelle, P.G., 2014. The effectiveness of computerized order entry at
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Rcoa.ac.uk (2018). The Royal College of Anaesthetists. [online] Rcoa.ac.uk. Available
at: https://www.rcoa.ac.uk/ [Accessed 19 Feb. 2018].
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and Miller, M.R., 2014. Interventions to reduce pediatric medication errors: a
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