A new infusion syringe label system designed to reduce task complexity during drug preparation.
A new safety-orientated drug infusion label was studied and was compared with conventional methods by prospectively collecting incident reports from November 1998 to November 2003. Anaesthetists were asked to return an incident form for every anaesthetic (87% response rate), the vast majority indicating that no error had occurred. One error was reported with the use of the new label. However, this was due to an incorrect patient weight being recorded in the notes, and the dose was correct for the information available. Therefore, this data point was not included in the analysis. Seven errors were reported in the calculation of dosage using conventional infusion labels during 18 491 anaesthetics compared with no calculation errors in 10 655 anaesthetics with the new label (p = 0.045, Chi-squared test). Despite the difficulties of demonstrating significant benefit from safety initiatives in medicine, these data suggest that targeted system redesign can be effective inreducing error.
Merry
A F
AF
Department of Anasethesiology, School of Medicine, University of Aukland, and Green Lane Department of Anaesthesia, Aukland City Hospital, Aukland, New Zealand. a.merry@auckland.ac.nz
Webster
C S
CS
Connell
H
H
D000758:Anesthesia / Q000592:standards*; D004334:Drug Administration Schedule; D004339:Drug Compounding / Q000379:methods* / Q000592:standards; D004348:Drug Labeling / Q000379:methods*; D004867:Equipment Design; D006801:Humans; D007262:Infusions, Intravenous; D008508:Medication Errors / Q000517:prevention & control*; D009520:New Zealand; D011446:Prospective Studies; D017751:Safety Management / Q000379:methods; D013594:Syringes; D014662:Vasoconstrictor Agents / Q000008:administration & dosage; D014665:Vasodilator Agents / Q000008:administration & dosage
D014662:Vasoconstrictor Agents; D014665:Vasodilator Agents