Annie Sheeba John, Thirilogasundary Murali Rajagopalan, Hemanth Kumar Vadlamudi Reddy
Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to Be University), Puducherry, India.
Department of Anaesthesiology, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry, India.
J Anaesthesiol Clin Pharmacol. 2019 Apr-Jun;35(2):220-226. doi: 10.4103/joacp.JOACP_178_18.
Safe medication is an important part of anesthesia practice. Even though anesthesia practice has become safer with various patient safety initiatives, it is not completely secure from errors which can sometimes lead to devastating complications. Multiple reports on medication errors have been published; yet, there exists a lacuna regarding the quantum of these events occurring in our country or the preventive measures taken. Hence, we conducted a survey to study the occurrence of medication errors, incident reporting, and preventive measures taken by anesthesiologists in our country.
A self-reporting survey questionnaire (24 questions, 4 parts) was mailed to 9000 anesthesiologists registered in Indian Society of Anaesthesiologists via Survey Monkey Website.
A total of 978 completed surveys were returned for analysis (response rate = 9.2%). More than two-thirds (75.6%, = 740) had experienced drug administration error and 7.7% (57) of respondents faced major morbidity and complications. Haste/Hurry (23.4%) was identified as the most common contributor to medication errors in the operation theater. Loading and double-checking of drugs before administration by concerned anesthesiologist were identified as safety measures to reduce drug errors.
Majority of our respondents have experienced drug administration error at some point in their career. A small yet important proportion of these errors have caused morbidity/mortality to patients. The critical incident reporting system should be established for regular audits, an effective root cause analysis of critical events, and to propose measures to prevent the same in future.
安全用药是麻醉实践的重要组成部分。尽管通过各种患者安全举措,麻醉实践已变得更加安全,但仍无法完全避免有时会导致严重并发症的差错。关于用药差错的多份报告已发表;然而,我国发生的此类事件数量以及所采取的预防措施方面仍存在空白。因此,我们开展了一项调查,以研究我国麻醉医生用药差错的发生情况、事件报告以及所采取的预防措施。
通过Survey Monkey网站向印度麻醉医师协会注册的9000名麻醉医生邮寄了一份自我报告调查问卷(24个问题,4部分)。
共收回978份完整调查问卷用于分析(回复率 = 9.2%)。超过三分之二(75.6%,n = 740)的人曾经历过给药差错,7.7%(57人)的受访者面临严重发病情况和并发症。匆忙/草率(23.4%)被确定为手术室用药差错最常见的促成因素。由相关麻醉医生在给药前对药物进行核对和再次核对被确定为减少用药差错的安全措施。
我们的大多数受访者在其职业生涯的某个阶段都经历过给药差错。这些差错中有一小部分但却很重要的比例给患者造成了发病/死亡。应建立关键事件报告系统,用于定期审计、对关键事件进行有效的根本原因分析,并提出未来预防此类事件的措施。