Medication errors in operating theatres in the department of anaesthesiology at the university of the Witwatersrand

Abstract

Background Medication errors occur commonly. They result in preventable morbidity and mortality and increased cost to the health care system. Anaesthetists are at high risk due to the number and potency of medications given in theatre. The occurrence of medication errors in operating theatres amongst anaesthetists at the University of the Witwatersrand is not currently known. Methods This is a prospective, contextual and descriptive study. A self-administered questionnaire was completed by anaesthetists at the University of the Witwatersrand (n=128). Results Ninety-three percent of participants reported a medication error or near miss event. A total of 231 events were reported. Medications most commonly involved were muscle relaxants, opioids and vasopressors. Substitution was the most common type of error, most often due to failure to check the label prior to administration. Fatigue was an important contributing factor. Events reported were most frequent during general anaesthesia, in adults, ASA I-II, elective patients during normal working hours. Only two cases of major morbidity occurred. No deaths were reported. No differences were found between consultant and junior anaesthetists. Conclusions Despite previous recommendations, medication errors and near miss events continue to occur in a similar manner. Negative patient outcomes have occurred with 2 cases of major morbidity reported in this study. Reporting of events remains low, but has improved. Measures should be instituted in order to decrease errors and improve incident reporting rates