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New guidelines to help avoid injectable anaesthetic errors

Measures for avoiding medication errors with the injectable agents used routinely in anaesthesia care have been recommended in new guidelines from the Association of Anaesthetists.

The guidelines, published in Anaesthesia, the journal of the Association of Anaesthetists, were drawn up "in response to requests for guidance from members in view of continuing incidents of medication errors and patient harm."

The working party of UK anaesthesia experts that drew up the guidance emphasised the potential safety benefits of using prefilled and labelled syringes, as well as aids such as colour-coded medication trays. It highlighted that these were not yet in widespread use within the NHS.

The group noted that unlike many healthcare workers, anaesthetists usually undertook medication preparation (transfer from labelled ampoules into unlabelled syringes) in a solo capacity, and that there could be an average of 10 medication administrations per anaesthetic procedure. Labelling errors have been reported in around 1–1.25% of peri-operative administrations, and medication substitutions in 0.2% of administrations during anaesthesia.

The working party, chaired by Dr Mike Kinsella, honorary consultant in the Department of Anaesthesia at University Hospitals Bristol and Weston, said it aimed "to provide pragmatic safety steps" for use within operating theatres, as well as goals for the development of "a collaborative approach to reducing errors" as a basis for "instilling good practice."

"It is important to acknowledge that every practitioner is open to error," the authors said, noting that the risk could increase over time during a case, especially if an anaesthetist's performance was diminished by fatigue. 

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Source: Medscape, 10 August 2023


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