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New Guidelines to Help Avoid Injectable Anaesthetic Errors

Measures for avoiding medication errors with the injectable agents used routinely in anaesthesia care have been recommended in new guidelines from the Association of Anaesthetists.

In particular, the working party of UK anaesthesia experts that drew up the guidance emphasised the potential safety benefits of using prefilled and labelled syringes, as well as aids such as colour-coded medication trays. 

It highlighted that these were not yet in widespread use within the NHS.

The guidelines, published in Anaesthesia, the journal of the Association of Anaesthetists, were drawn up "in response to requests for guidance from members in view of continuing incidents of medication errors and patient harm". 

Anaesthetists Usually Work Solo

The group noted that unlike many healthcare workers, anaesthetists usually undertook medication preparation (transfer from labelled ampoules into unlabelled syringes) in a solo capacity, and that there could be an average of 10 medication administrations per anaesthetic procedure. Labelling errors have been reported in around 1–1.25% of peri-operative administrations, and medication substitutions in 0.2% of administrations during anaesthesia, "although precise figures are lacking".

The working party, chaired by Dr Mike Kinsella, honorary consultant in the Department of Anaesthesia at University Hospitals Bristol and Weston, said it aimed "to provide pragmatic safety steps" for use within operating theatres, as well as goals for the development of "a collaborative approach to reducing errors" as a basis for "instilling good practice".

"It is important to acknowledge that every practitioner is open to error," the authors said, noting that the risk could increase over time during a case, especially if an anaesthetist's performance was diminished by fatigue. 

Supportive Systems Needed Within Hospitals 

However, the group stressed that patient safety did not depend solely on individual anaesthetists’ practice, relied on supportive systems within hospitals, and that other hospital departments should also contribute to safe systems. "Peri-operative medication safety is complex," the authors said, and "avoidance of medication errors is both system- and practitioner-based". 

Past research has shown that injectable medicines are associated with a higher incidence of errors than others . Reported safety errors in anaesthesia have included mis-selection of a drug, incorrect drug strength, administration by the wrong route, and overdose due to the use of abbreviations or an incorrect device. Recognised reasons for anaesthetic medication administration errors included ampoules with similar appearance and packaging, ineffective communication, clinician inattention, fatigue, and haste.

The working party emphasised the "importance, utility, and enhanced safety" offered by prefilled and labelled medication syringes, as well as aids such as colour-coded medication trays to help the anaesthetist correctly organise syringes before and during anaesthesia. However, neither of these were yet in widespread use in the NHS.

Advice for Hospitals and Individuals

Other recommendations included:

  • Clear institutional policy on safe handling of medicines both within departments — especially departments of anaesthesia — and with individual practice. Senior management should promote organisational safety consciousness, with collaborative cross-departmental and cross-speciality working
  • Pharmacy departments should promote purchasing for safety, consistent supply, and buy from companies complying with good labelling practice. There should be a named anaesthetist to liaise with the pharmacy team
  • The purchase and use of prefilled and labelled syringes should be promoted, as these reduce labelling errors and bacterial contamination, and hold the potential for tamper-evidence and medication recognition mechanisms
  • Fit-for-purpose physical structure and medicine storage in workplaces should be developed and standardised
  • Syringe labelling and handling practices should be promoted, standardised, and form part of the anaesthetist training curriculum
  • Specific characteristics of individual anaesthetists that affect their working (for example visual acuity, colour blindness, hearing impairments or physical problems) should be recognised by the individual and their department, and suitable adjustments to practice made

The guidelines have been endorsed by the Chartered Institute of Ergonomics and Human Factors, the International Society of Pharmacovigilance, the Royal College of Anaesthetists, and the Royal Pharmaceutical Society (RPS), and are supported by the Safe Anaesthesia Liaison Group.

Analysis Welcomed by NHS

Commenting to Medscape News UK, RPS Director for England James Davies said: "These guidelines build on the professional guidance on the safe and secure handling of medicines from the RPS, and demonstrate the key role that pharmacy teams have to play in supporting the safe and effective use of medicines."

NHS England said it welcomed the detailed analysis and would "examine the evidence behind these recommendations during decision-making".

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