4.4 IV drug errors Flashcards
a) Which human factors contribute to intravenous drug administration errors in theatre-based anaesthetic
practice? (30%)
Lack of knowledge:
» Unfamiliarity with a particular drug,
its route of administration etc.
Human cognition: >> Human memory – cannot be relied upon to remember all infusion mixtures, dose variations etc.
> > Difficulty with complex calculations,
e.g. paediatrics, infusions.
> > Lack of knowledge of certain unfamiliar drugs.
Distraction:
» Needing to address other tasks
whilst also drawing up drugs, prescribing
drugs, calculating doses, giving drugs.
> > High noise levels.
Stress and fatigue:
» Tiredness, e.g. due to night work.
> > Non-work emotional issues causing reduced work performance.
Lack of teamwork:
» Lack of double checking of drugs.
> > Failure to feel able to voice lack of knowledge about a particular drug and its administration.
> > Failure to implement a ‘no blame culture,’ lack of encouragement of reporting and learning from errors.
> > Poor communication, poor handover:
failure of one member of a team to give explicit instructions to another about the administration of a particular drug or whether a drug has already been given.
Excessive physical demands:
» Excessive workload,
e.g. high turnover list.
Physical environment:
» Cluttered workspace, low light levels.
> > Drugs with similar packaging,
changes in packaging without notice,
unclear or too small labelling and lettering size.
b) Outline the organisational strategies that might minimise intravenous drug administration errors. (70%)
Processes
Processes:
» Standardisation of cross-checking, handover etc.
> > Standardisation of infusion doses, diluents etc.
> > Availability of reference databases
for doses, calculations, diluents.
> > Regulations regarding what is drawn up
and by whom and at what stage
in the care of a patient.
> > Avoidance of distraction during drug preparation.
> > Checklist to ensure prescription
chart checked before administration
of drugs by anaesthetist to avoid
double-dosing or omitted doses.
> > Investigation of possibility of pre-mixed infusions.
> > Flushing all lines as standard
before leaving theatre and recovery.
b) Outline the organisational strategies that might minimise intravenous drug administration errors. (70%)
Environment
Physical environment:
> > Standardisation of lay-out and
contents of anaesthetic carts.
> > Ensure intrathecal/epidural drugs kept
separate from intravenous drugs.
> > Removal of non-essential,
rarely used drugs from cart which have high
injury risk if inadvertently given.
> > Ensuring label availability at all times.
>> Process for dealing with unused ampoules to prevent them from being returned to incorrect box (e.g. second-person check or discard altogether).
> > Ensure adequate lighting levels.
> > Sourcing of products with clear labelling, sufficiently large lettering etc., where possible.
b) Outline the organisational strategies that might minimise intravenous drug administration errors. (70%)
Team Work
Management of Error
Team working:
» Simulation sessions to highlight
risks to all team members.
> > Unusual drugs to be dealt with in the team briefing.
> > Encouragement of working
environment where any team member feels
able to voice concern.
>> Inclusion of pharmacist in team: notification of team members about changes in product appearance, education about new drugs for inclusion in anaesthetic carts etc
Management of error:
» Open incident reporting with no-blame culture,
lead clinician who will analyse factors contributing to error and be responsible for national reporting.
Morbidity and mortality meetings for education of all team members about pitfalls that may lead to error.
> > Communication of e.g.
Safe Anaesthesia Liaison Group reports to all
team members to help everyone learn from errors that have occurred nationally.
b) Outline the organisational strategies that might minimise intravenous drug administration errors. (70%)
Processes:
Physical environment:
Team Work
Management of Error
