Incidence of anesthesia-related medication errors over a 15-year period in a university hospital.
To clarify the incidence of anesthesia-related medication errors in Kyushu University Hospital, a retrospective analysis of anesthesia-related incidents from 1993 to 2007 was conducted based on the "Investigation of anesthesia-related medication incidents" by the Japanese Society of Anesthesiologists. Out of a total of 64,285 anesthesia cases, drug errors occurred in 50 cases (0.078%), but none of the incidents led to serious sequelae. Wrong medication was the most common type of drug error (48%), followed by overdose (38%), underdose (4%), omission (2%), and incorrect administration route (8%). The most commonly involved drugs were opioids, cardiac stimulants, and vasopressors. Syringe swap was the leading cause of wrong medication, accounting for 42%, drug ampoule swap occurred in 33%, and the wrong choice of drug was made in 17%. The first, second, and third most frequent causes of overdose involved a misunderstanding or preconception of the dose (53%), pump misuse (21%), and dilution error (5%). The error frequency did not decrease over the 15-year period. The responsible anesthesiologists were most likely to be doctors with a little experience. To reduce anesthesia-related medication errors, improvements of protocols for handling medication and instruction, and an improved education system for the anesthesia trainees are essential.
Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan. yoshiro@kuaccm.med.kyushu-u.ac.jp
Yoshiro
Y
Sakaguchi
Kentaro
K
Tokuda
Kana
K
Yamaguchi
Kazuo
K
Irita
D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects; D000758:Anesthesia / Q000706:statistics & numerical data*; D000776:Anesthesiology / Q000193:education; D000777:Anesthetics / Q000008:administration & dosage* / Q000009:adverse effects; D002316:Cardiotonic Agents / Q000008:administration & dosage / Q000009:adverse effects; D002983:Clinical Competence; D062787:Drug Overdose / Q000453:epidemiology; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D007564:Japan / Q000453:epidemiology; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013997:Time Factors
D000701:Analgesics, Opioid; D000777:Anesthetics; D002316:Cardiotonic Agents