Drug related critical incidents.
Drug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect/drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.
Khan
F A
FA
Department of Anaesthesia, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan. fanzia.khan@aku.edu
Hoda
M Q
MQ
D000758:Anesthesia / Q000009:adverse effects* / Q000592:standards; D003906:Developing Countries; D064420:Drug-Related Side Effects and Adverse Reactions; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data* / Q000639:trends; D009466:Neuromuscular Blocking Agents / Q000009:adverse effects; D010154:Pakistan; D017751:Safety Management / Q000379:methods
D009466:Neuromuscular Blocking Agents