[Current Situation Survey of the Measures to Prevent Medication Errors in the Operating Room: Report of the Japan Society of Anesthesiologists Safety Commission Working Group for Consideration of Recommendations for Color Coding of Prepared Syringe Labels for Prevention of Medication Errors].

BACKGROUND

In the case of medication errors which are among the more frequent adverse events that occur in the hospital, there is a need for effective measures to prevent incidence. According to the Japan Society of Anesthesiologists study "Drug incident investigation 2005-2007 years", "Error of a syringe at the selection stage" was the most frequent (44.2%). The status of current measures and best practices implemented in Japanese hospitals was the focus of a subsequent investigation.

METHODS

Representative specialists in anesthesiology certified hospitals across the country were surveyed via a questionnaire sampling that lasted 46 days. Investigation method was via the Web with survey responses anonymous.

RESULTS

With respect to preventive measures implemented to mitigate risk of medication errors in perioperative settings, responses included: incident and accident report (215 facilities, 70.3%), use of pre-filled syringes (180 facilities, 58.8%), devised the arrangement of dangerous drugs (154 facilities, 50.3%), use of the product with improper connection preventing mechanism (123 facilities, 40.2%), double-check (116 facilities, 37.9%), use of color barreled syringe (115 facilities, 37.6%), use of color label or color tape (89 facilities, 29.1%), presentation of medication such as placing the ampoule or syringe on a tray by dividing color code for drug class on a tray (54 facilities, 17.6%), the discontinuance of handwritten labels (23 facilities, 7.5%), use of a drug verification system that uses bar code (20 facilities, 6.5%), and facilities that have not implemented any means (11 facilities, 3.6%), others not mentioned (10 facilities, 3.3%), and use of carts that count/account the agents by drug type and record selection and number picked automatically (6 facilities, 2.0%). Drug name identification affixed to the syringe via perforated label torn from the ampoule/vial, etc. (245 facilities, 28.1%), handwriting directly to the syringe (208 facilities, 23.8%), use of the attached label (like that comes with the product) (187 facilities, 21.4%), handwriting on the plain tape (87 facilities, 10.0%), printing labels (62 facilities, 7.1%), printed color labels (44 facilities, 5.0%), handwriting on the color tape (27 facilities, 3.1%), machinery for printing the drug name by scanning bar code of the ampoule, etc.(10 facilities, 1.1%), others (3 facilities, 0.3%), no description on the prepared drug (0 facilities, 0%). The awareness of international standard color code, such as by the International Organization for Standardization (ISO), was only 18.6%.

CONCLUSIONS

Targeting anesthesiology certified hospitals recognized by the Japan Society of Anesthesiologists, the result of the survey on the measures to prevent medication errors during perioperative procedures indicated that various measures were documented in use. However, many facilities still use hand written labels (a common cause for errors). Confirmation of the need for improved drug name and drug recognition on syringe was documented.