Drug errors in anaesthetic practice
In 2017 the World Health Organization aimed to reduce severe avoidable medicationrelated harm by 40% within five years [1]. Let’s be clear - drug errors will always be with us; they are not going to be never events. In fact, as systems and technology get more complex they can mitigate some ‘human errors’, but at the expense of more major failures when there is the (inevitable) breakdown.
However, I’m not advocating nihilism – far from it. I think we needto work from the bottom up – that means the drones – you and I. There are systems which could (probably) help significantly such as barcode checking for each drug administration, and prefilled syringes, but let’s not wait for those to be introduced into the under-resourced NHS, with our heads deep in the sand in the meantime.
I commend to you a recent editorial in Anaesthesia [2]; the accompanying infographic (Figure 1) deserves to be put up where we can read and reflect regularly [3]. The authors suggest twelve rules for safety; I will go through a few of these, out of order, with my own personal slant.
Check, mate (Rules 1, 2, 3)
Brains work best without too much overload. Aim to prepare the most important drugs (dangerous in overdose; double dilutions; the most vulnerable anatomical spaces; etc) first – one at a time, no distractions, check and recheck.
Enemies in high places (Rule 1)
Read the label. It sounds fairly simple, but we often work on automatic mode where we ‘expect the expected’.
When I was a first year S.H.O. I was finishing the anaesthetic for a teenager having an appendicectomy. At that time the reversal drugs were kept in a little foam block on the top tray of the anaesthetic machine. I drew up my neuromuscular blocker reversal, one amber ampoule and two clear glass ampoules. Just before giving it, I looked at the ampoules. I had 2 mg of adrenaline in my syringe, rather than 1.2 mg atropine….that certainly would have ensured no bradycardia from neostigmine, with room to spare…
I found a couple of other 1 ml adrenaline ampoules in the block as well as the expected atropine ones, and threw them out rapidly. Was I the first person to have anaesthetised after someone helpfully restocked the drugs? – I don’t know, we didn't have a critical incident system at that time to alert others to potential problems.
But this leads on to…
The wrong box (a 1966 comedy film with Peter Sellers, but in this context....)
Our assistants do a great job, but they don’t have the same safety priorities, and can lead us into trouble accidentally. The resupply of the reversal drugs I just mentioned was done by an O.D.P. Figure 2 shows the latest (from a regular stream) ‘wrong box’ incident circulated on our consultants WhatsApp group. The Trust has a policy of not replacing single ampoules back in boxes – they should be thrown away, or at the least returned to the cupboard in isolation. However, this message is almost unknown among our assistants.
Separate and lift
Rule 10 is a little ambiguous. ‘Dangerous’ (in a broad sense) drugs should not be kept in the same place as intravenous medications. I think this mainly refers to the anaesthetic workstation. Following on from the previous point, oxytocin can be drawn up just a few seconds before delivery; but if not, it should be well away from the core drugs so that it does not get picked up accidentally [4] – I notice it is often placed on the
anaesthetic machine top tray.
My oxytocin near-miss happened at a caesarean section when I drew it up into a 2 ml syringe near to the anticipated delivery. The woman then developed discomfort, so I drew up alfentanil, also into a 2 ml syringe, in readiness to treat pain. Somehow the syringes got swapped, and I stopped myself giving oxytocin only by the realisation that I was holding a syringe with 1 ml of contents rather than 2 ml. I am now currently using a 1 ml syringe for oxytocin [4] (Rule 5 – use different syringe sizes for different medications).
We have invested in cheap yellow trays from a local megastore in order to segregate neuraxial drugs (did I say that I once gave vasopressor into the epidural catheter?). The rainbow tray [5] merits further development (Rule 5).
However, Rule 10 should also be applied to drug storage in cupboards / trolleys / etc. Tranexamic acid, a ‘friend’ in the war against haemorrhage, has become readily available in theatres and the labour ward. Unfortunately it may be presented in a form very similar to bupivacaine, and when given spinally it almost always causes permanent harm or death [6]. It must be kept well separated from the general spinal drugs.
Two syringes -again
I drew up my reversal into a 5 ml syringe at the end of general anaesthesia for a cataract extraction. Soon after, I administered the contents of a 5 ml syringe – and then to my horror realised that this was another paralysing dose of alcuronium, not the reversal which had been sitting next to it in the tray. No significant harm done to the patient, although that couldn’t be said for the list throughput. Since then I squirt and empty my neuromuscular blocker syringe before drawing up reversal (Rule 7).
Gert flush (Rule 11).
With the proliferation of extensions, needleless ports, etc, the opportunities for a significant deadspace filled with an unintended drug are increasing. NHS England issued Safety Alert NHS/PSA/D/2017/006, and requested that ‘Have the lines been flushed?’ is included in the WHO signout
[7]. This reference gives a patient’s horror story of what can happen [7].
Further reading
The Association of Anaesthetists have a working party which is planning to issue guidance on syringe labelling and medicines handling. We are considering two detailed documents that cover this area of practice: the Australian and New Zealand College of Anaesthetists ‘Guidelines for the Safe Management and Use of Medications in Anaesthesia’ [8] and the European Board of Anaesthesiology ‘Recommendations for safe medication practice’ [9]. We do not wish to reinvent the wheel, and therefore it is likely that we will produce a shorter document than either of these, but link to them for further reference.
All men make mistakes, but only wise men learn from their mistakes – Winston Churchill
I have always tried to follow the rule that, if I make an error, I won’t do the same again.
I keep to it sometimes…!
Mike Kinsella
Association of Anaesthetists Safety Committee Member