Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study
Abstract Background Drug administration errors (DAEs) in anaesthesia are common, the aetiology multifactorial and though mostly inconsequential, some lead to substantial harm. The extend of DAEs remain poorly quantified and effective implementation of prevention strategies sparse. Method A cross-sec...
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BMC
2024-08-01
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| Series: | BMC Anesthesiology |
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| Online Access: | https://doi.org/10.1186/s12871-024-02657-9 |
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| author | René van Wyk Ryan Alroy Davids |
| author_facet | René van Wyk Ryan Alroy Davids |
| author_sort | René van Wyk |
| collection | DOAJ |
| description | Abstract Background Drug administration errors (DAEs) in anaesthesia are common, the aetiology multifactorial and though mostly inconsequential, some lead to substantial harm. The extend of DAEs remain poorly quantified and effective implementation of prevention strategies sparse. Method A cross-sectional descriptive study was conducted using a peer-reviewed survey questionnaire, circulated to 2217 anaesthetists via a national communication platform. The aim was to determine the self-reported frequency, nature, contributing factors and reporting patterns of DAEs among anaesthesia providers in South Africa. Results Our cohort had a response rate was 18.9%, with 420 individuals populating the questionnaire. 92.5% of surveyed participants have made a DAE and 89.2% a near-miss. Incorrect route of administration, potentially resulting in serious harm, accounted for 8.2% (n = 23/N = 279) of these errors. DAEs mostly reported in cases involving adult patients (80.5%, n = 243/N = 302), receiving a general anaesthetic (71.8%, n = 216/N = 301), where the drug-administrator prepared the drugs themselves (78.7%, n = 218/N = 277), during normal daytime hours (69.9%, n = 202/N = 289) with good lightning conditions (93.0%, n = 265/N = 285). 26% (n = 80/N = 305) of DAEs involved ampoule misidentification, whilst syringe identification error reported in 51.6% (n = 150/N = 291) of cases. DAEs are often not reported (40.3%, n = 114/N = 283), with knowledge of correct reporting procedures lacking. 70.5% (n = 198/N = 281) of DAEs were never discussed with the patient. Conclusions DAEs in anaesthesia remain prevalent. Known error traps continue to drive these incidents. Implementation of system based preventative strategies are paramount to guard against human error. Efforts should be made to encourage scrupulous reporting and training of anaesthesia providers, with the aim of rendering them proficient and resilient to handle these events. |
| format | Article |
| id | doaj-art-00fa629d792a418b8e65b3418499ff88 |
| institution | Kabale University |
| issn | 1471-2253 |
| language | English |
| publishDate | 2024-08-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Anesthesiology |
| spelling | doaj-art-00fa629d792a418b8e65b3418499ff882025-02-09T12:52:04ZengBMCBMC Anesthesiology1471-22532024-08-012411910.1186/s12871-024-02657-9Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive studyRené van Wyk0Ryan Alroy Davids1Department Anaesthesiology and Critical Care, University of StellenboschDepartment Anaesthesiology and Critical Care, University of StellenboschAbstract Background Drug administration errors (DAEs) in anaesthesia are common, the aetiology multifactorial and though mostly inconsequential, some lead to substantial harm. The extend of DAEs remain poorly quantified and effective implementation of prevention strategies sparse. Method A cross-sectional descriptive study was conducted using a peer-reviewed survey questionnaire, circulated to 2217 anaesthetists via a national communication platform. The aim was to determine the self-reported frequency, nature, contributing factors and reporting patterns of DAEs among anaesthesia providers in South Africa. Results Our cohort had a response rate was 18.9%, with 420 individuals populating the questionnaire. 92.5% of surveyed participants have made a DAE and 89.2% a near-miss. Incorrect route of administration, potentially resulting in serious harm, accounted for 8.2% (n = 23/N = 279) of these errors. DAEs mostly reported in cases involving adult patients (80.5%, n = 243/N = 302), receiving a general anaesthetic (71.8%, n = 216/N = 301), where the drug-administrator prepared the drugs themselves (78.7%, n = 218/N = 277), during normal daytime hours (69.9%, n = 202/N = 289) with good lightning conditions (93.0%, n = 265/N = 285). 26% (n = 80/N = 305) of DAEs involved ampoule misidentification, whilst syringe identification error reported in 51.6% (n = 150/N = 291) of cases. DAEs are often not reported (40.3%, n = 114/N = 283), with knowledge of correct reporting procedures lacking. 70.5% (n = 198/N = 281) of DAEs were never discussed with the patient. Conclusions DAEs in anaesthesia remain prevalent. Known error traps continue to drive these incidents. Implementation of system based preventative strategies are paramount to guard against human error. Efforts should be made to encourage scrupulous reporting and training of anaesthesia providers, with the aim of rendering them proficient and resilient to handle these events.https://doi.org/10.1186/s12871-024-02657-9Anaesthesia errorsContributing factorsDrug administration errorsMedication errorsReporting of drug errors |
| spellingShingle | René van Wyk Ryan Alroy Davids Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study BMC Anesthesiology Anaesthesia errors Contributing factors Drug administration errors Medication errors Reporting of drug errors |
| title | Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study |
| title_full | Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study |
| title_fullStr | Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study |
| title_full_unstemmed | Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study |
| title_short | Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study |
| title_sort | drug administration errors among anaesthesia providers in south africa a cross sectional descriptive study |
| topic | Anaesthesia errors Contributing factors Drug administration errors Medication errors Reporting of drug errors |
| url | https://doi.org/10.1186/s12871-024-02657-9 |
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