title: Profile of drug administration errors in anesthesia among anesthesiologists from Santa Catarina.
abstract: BACKGROUND
  Anesthesiology is the only medical specialty that prescribes, dilutes, and administers drugs without conferral by another professional. Adding to the high frequency of drug administration, a propitious scenario to errors is created.
  
  
  OBJECTIVE
  Access the prevalence of drug administration errors during anesthesia among anesthesiologists from Santa Catarina, the circumstances in which they occurred, and possible associated factors.
  
  
  METHODS
  An electronic questionnaire was sent to all anesthesiologists from Sociedade de Anestesiologia do Estado de Santa Catarina, with direct or multiple choice questions on responder demographics and anesthesia practice profile; prevalence of errors, type and consequence of error; and factors that may have contributed to the errors.
  
  
  RESULTS
  Of the respondents, 91.8% reported they had committed administration errors, adding the total error of 274 and mean of 4.7 (6.9) errors per respondent. The most common error was replacement (68.4%), followed by dose error (49.1%), and omission (35%). Only 7% of respondents reported neuraxial administration error. Regarding circumstances of errors, they mainly occurred in the morning (32.7%), in anesthesia maintenance (49%), with 47.8% without harm to the patient and 1.75% with the highest morbidity and irreversible damage, and 87.3% of cases with immediate identification. As for possible contributing factors, the most frequent were distraction and fatigue (64.9%) and misreading of labels, ampoules, or syringes (54.4%).
  
  
  CONCLUSIONS
  Most respondents committed more than one error in anesthesia administration, mainly justified as a distraction or fatigue, and of low gravity.
authors.affiliation: Hospital Governador Celso Ramos, Florianópolis, SC, Brazil. Electronic address: thomaserdmann@hotmail.com.
authors.forename: Thomas Rolf
authors.initials: TR
authors.lastname: Erdmann
authors.affiliation: Hospital Governador Celso Ramos, Florianópolis, SC, Brazil.
authors.forename: Jorge Hamilton Soares
authors.initials: JH
authors.lastname: Garcia
authors.affiliation: Hospital Governador Celso Ramos, Florianópolis, SC, Brazil.
authors.forename: Marcos Lázaro
authors.initials: ML
authors.lastname: Loureiro
authors.affiliation: Hospital Governador Celso Ramos, Florianópolis, SC, Brazil.
authors.forename: Marcelo Petruccelli
authors.initials: MP
authors.lastname: Monteiro
authors.affiliation: Hospital Governador Celso Ramos, Florianópolis, SC, Brazil.
authors.forename: Guilherme Muriano
authors.initials: GM
authors.lastname: Brunharo
mesh_terms: D000328:Adult; D000758:Anesthesia / Q000009:adverse effects / Q000379:methods*; D000072080:Anesthesiologists / Q000592:standards* / Q000706:statistics & numerical data; D000776:Anesthesiology / Q000592:standards / Q000706:statistics & numerical data; D000777:Anesthetics / Q000008:administration & dosage* / Q000009:adverse effects; D001938:Brazil; D005260:Female; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000706:statistics & numerical data*; D008875:Middle Aged; D015995:Prevalence; D011795:Surveys and Questionnaires
chemical_list: D000777:Anesthetics
keywords: Anestesia; Anestesiologia; Anesthesia; Anesthesiology; Drug errors; Erros de medicação; Erros médicos; Medical errors