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.
Sakaguchi
Yoshiro
Y
Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan. yoshiro@kuaccm.med.kyushu-u.ac.jp
Tokuda
Kentaro
K
Yamaguchi
Kana
K
Irita
Kazuo
K
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