Gordon P C, Llewellyn R L, James M F M
Department of Anaesthesia, Groote Schuur Hospital and University of Cape Town.
S Afr Med J. 2006 Jul;96(7):630-2.
To investigate the incidence, nature of and factors contributing towards wrong drug administrations by South African anaesthetists.
A confidential, self-reporting survey was sent out to the 720 anaesthetists on the database of the South African Society of Anaesthesiologists.
A total of 133 questionnaires were returned for analysis (18.5% response rate). Of the respondents, 125 (94%) admitted to having inadvertently administered a wrong drug. Thirty respondents (22.6%) said they had made errors on at least four occasions. A total of 303 specific wrong drug administrations were described. Nearly 50% involved muscle relaxants. A further 43 incidents (14%) involved the erroneous administration of vasoactive drugs. Five deaths and 3 nonfatal cardiac arrests were reported. In 9.9% of incidents the anaesthetic time was prolonged by more than 30 minutes. Contributory causes identified included syringe swaps (40%), misidentification of drugs (27.1%), fatigue (14.1%), distractions (4.7%), and mislabelling of syringes (4.7%). Only 19% of respondents regularly use colour-coded syringe labels complying with the national standard.
Most anaesthetists experienced at least one drug error. The incidence of wrong drug administrations by South African anaesthetists appears to be similar to that in Australasia and Canada. The commonest error was a 'syringe swap' involving muscle relaxants. Most drug errors are inconsequential. An important minority of incidents result in severe morbidity or death. The study supports efforts to improve ampoule labelling, to encourage the use of syringe labels based on the international colour code and to develop a national reporting system for such incidents.
调查南非麻醉医生用药错误的发生率、性质及相关因素。
向南非麻醉医师协会数据库中的720名麻醉医生发送了一份保密的自我报告调查问卷。
共收回133份问卷用于分析（回复率为18.5%）。在受访者中，125人（94%）承认曾无意中使用了错误的药物。30名受访者（22.6%）表示他们至少有四次失误。共描述了303起具体的用药错误事件。近50%涉及肌肉松弛剂。另有43起事件（14%）涉及血管活性药物的错误使用。报告了5例死亡和3例非致命性心脏骤停。在9.9%的事件中，麻醉时间延长了30分钟以上。确定的促成因素包括注射器互换（40%）、药物误认（27.1%）、疲劳（14.1%）、分心（4.7%）和注射器标签错误（4.7%）。只有19%的受访者经常使用符合国家标准的彩色编码注射器标签。
大多数麻醉医生至少经历过一次用药错误。南非麻醉医生用药错误的发生率似乎与澳大利亚和加拿大相似。最常见的错误是涉及肌肉松弛剂的“注射器互换”。大多数用药错误没有造成严重后果。一小部分重要事件导致严重发病或死亡。该研究支持改进安瓿标签、鼓励使用基于国际颜色代码的注射器标签以及建立此类事件的国家报告系统的努力。
