Division of Clinical Neuroscience, Anaesthesia and Critical Care, University of Nottingham, Nottingham, UK.
Pilgrim Hospital, Boston, UK.
Anaesthesia. 2018 Mar;73(3):356-364. doi: 10.1111/anae.14187. Epub 2018 Jan 3.
Drug errors in the anaesthetic domain remain a serious cause of iatrogenic harm. To help reduce this issue, we explored the potential safety impact of using a simple colour-coded tray for anaesthetic drug preparation and storage. Over a six-month period, three different trained researchers observed 30 cases at three NHS Trusts. Ten observations involved standard drug trays in 'normal' practice, and 20 observations, involved 'Rainbow trays' before and after their introduction. We conducted 20 semi-structured interviews immediately after completing the Rainbow tray observation with the anaesthetists involved. All discussions and detailed notes taken were transcribed, qualitatively analysed using line-by-line coding and then synthesised into narrative themes. We found that using standard, single compartment trays enabled quick, cheap, and portable drug preparation and storage, but was linked to potential or actual harmful errors, such as syringe swaps. Rainbow trays were perceived to be easy to use and effective at all three sites, aiding drug identification and separation, and hence likely to reduce drug error and increase patient safety. We have demonstrated that it is feasible to introduce a new colour-coded compartmentalised Rainbow drugs tray into clinical practice at three NHS hospitals in England. Further research is needed into their effect on the prevalence of drug error.
麻醉领域的药物错误仍然是造成医源性伤害的一个严重原因。为了帮助减少这个问题，我们探讨了使用简单的彩色编码托盘进行麻醉药物准备和储存对安全性的潜在影响。在六个月的时间里，三位经过培训的研究人员在三家 NHS 信托机构观察了 30 例案例。其中 10 次观察涉及“正常”实践中的标准药物托盘，另外 20 次观察涉及在引入“彩虹托盘”前后的情况。我们在完成彩虹托盘观察后立即对涉及的麻醉师进行了 20 次半结构化访谈。所有讨论和详细记录都被转录下来，采用逐行编码进行定性分析，然后综合成叙事主题。我们发现，使用标准的单隔室托盘可以快速、廉价且便携地进行药物准备和储存，但与潜在或实际的有害错误（如注射器更换）有关。彩虹托盘在所有三个地点都被认为易于使用且有效，有助于药物识别和分离，因此可能会减少药物错误并提高患者安全性。我们已经证明，在英格兰的三家 NHS 医院引入新的彩色编码分隔式彩虹药物托盘是可行的。需要进一步研究它们对药物错误发生率的影响。
