Preventing medication errors in the perioperative setting: recommendations on drug syringe labels

Excerpt

Among the adverse events that occur in hospitals, errors in the selection and use of the correct drug happen with a high degree of frequency, and 89% of anesthesiologists have encountered this problem in the perioperative setting [1]. According to an investigation conducted by the Japanese Society of Anesthesiologists (JSA), “Drug incident investigation 2005–2007” [2], medication errors during anesthesia occurred at a rate of at least 39.2 per 100,000 cases. Cases of advanced fault detection were also reported, and it is clear that prevention measures are necessary. According to the same report, “errors at the syringe selection stage” (44.2%) were the single highest cause of the wrong drug being used in anesthesia. In August 2014, the JSA sent out a questionnaire entitled “Current status of measures to prevent medication errors in operating rooms” to JSA Certified Training Hospitals. While a number of preventative measures have been or are being implemented by the sites sampled, the results of the questionnaire revealed a less than satisfactory situation. In particular, only 7.5% of hospitals (23 of 306 facilities) have discontinued the use of handwritten labels. The use of such labels is a problem as it is easy to make a mistake either in writing or reading them. Therefore, the current drug syringe label situation has been documented as one of the primary causes of error. …