Fasting S, Gisvold S E
Department of Anesthesia and Intensive Care, University Hospital of Trondheim, Norway.
Can J Anaesth. 2000 Nov;47(11):1060-7. doi: 10.1007/BF03027956.
To describe the frequency and pattern of drug errors in clinical anesthesia, and to evaluate whether a change to colour coded syringe labels, along with education, could reduce the problem of drug errors.
We prospectively recorded anesthesia-related information from all anesthetic cases for 36 mo, totally 55,426 procedures. Intraoperative problems, including drug errors, were recorded. After eighteen months we changed to colour coded syringe labels, and the effect of this change and education on drug errors was assessed. Errors were divided into four groups: syringe swap, ampoule swap, other 'wrong drug' errors, and wrong dose errors. The problems were graded into four levels, according to severity.
A drug error was recorded in 63 cases (0.11%). There were 28 syringe swaps, and muscle relaxants were erroneously given in 15. There were nine ampoule swaps. There were eight 'other wrong drug' cases, and 18 cases where a wrong dose of the correct drug was given. Three of the drug errors were classified as serious, and 27 were of moderate severity. We found no differences between the two periods except for decreased number of ampoule swaps (P = 0.04).
Drug errors are uncommon, and represent a small part of anesthesia problems but still have the potential for serious morbidity. Syringe swaps occurred most often between syringes of equal size, and were not eliminated by colour coding of labels. As muscle relaxant drugs are most commonly involved, and can cause lasting morbidity, special preventive measures should be taken for this group of drugs.
描述临床麻醉中用药错误的频率和模式，并评估采用彩色编码注射器标签以及开展教育能否减少用药错误问题。
我们前瞻性地记录了36个月内所有麻醉病例的麻醉相关信息，共55426例手术。记录术中问题，包括用药错误。18个月后，我们改用彩色编码注射器标签，并评估这一改变及教育对用药错误的影响。错误分为四组：注射器互换、安瓿互换、其他“用错药”错误和剂量错误。根据严重程度将问题分为四个等级。
记录到63例用药错误（0.11%）。有28例注射器互换，其中15例误注了肌肉松弛剂。有9例安瓿互换。有8例“其他用错药”情况，18例出现了正确药物的剂量错误。3例用药错误被归类为严重，27例为中度严重。除安瓿互换数量减少外（P = 0.04），我们发现两个时期之间没有差异。
用药错误并不常见，占麻醉问题的一小部分，但仍有导致严重发病的可能性。注射器互换最常发生在同等大小的注射器之间，标签的彩色编码并未消除这种情况。由于肌肉松弛剂药物最常涉及，且可导致持久性发病，应对这类药物采取特殊的预防措施。
