This document discusses critical incident reporting in anaesthesia, with a focus on drug errors. It begins by defining critical incidents and near misses in anaesthesia. It then discusses the causes of critical incidents, including human errors and latent failures. The document outlines the components of an effective incident reporting system, including independent reporting, analysis by subject matter experts, and feedback. It analyzes reported incidents to identify areas for improvement. Drug errors are defined and classified, with risk factors and consequences discussed. The prevention of drug errors focuses on vigilance, standardized protocols, and thinking before acting.

1. CRITICAL INCIDENT REPORTING
IN ANAESTHESIA: DRUG ERRORS
DR. UBA

2. Outline
• Introduction
• Causes of critical incidents
• Components of incident reporting system
• Analysis of reported incidents
• Components of incident analysis
• Barriers and enablers to successful incident reporting
• Drug errors
• Classification of drug errors
• Risk factors for drug errors
• Consequences of drug errors
• Prevention of drug errors
• Conclusion
• References
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3. Introduction
• A critical incident in anaesthesia is defined as
any untoward and preventable mishap
associated with the administration of general
or regional anaesthesia, and which leads to, or
could have led to an undesirable patient
outcome.
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4. • Near miss: an event which has the potential to
lead to the substantial negative outcome if left
to progress
• Never event: serious, largely preventable
patient safety incidents that should not occur
if relevant preventive measures have been put
in place
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5. LUTH, 2017
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6. Causes Of Critical Incidents
• Contributory factors: patient, surgery or
anaesthesia
• Anaesthesia-related critical incidents may be
due to human errors, equipment errors, or
pharmacological factors.
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7. Human Errors
• Due to active and/or latent failures
• Active failures: unsafe acts or omissions
performed by front-end workers i.e.
anaesthetists, surgeons, nurses
– Slips: wrong label/syringe
– Cognitive failure: memory lapses, ignorance,
misreading a situation
– Violations: deviations from safe practices,
procedures or standards
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8. • Latent failures: decisions taken by senior
management or clinicians, which create the
conditions in an organization for unsafe acts to
occur
– Inadequate or inappropriate staffing
– Heavy workload
– Poor supervision
– Stressful environment
– Poor communication
– Poor maintenance of equipment
– Conflict of priorities (finance vs. clinical need)
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9. Incident Reporting Systems
• The main reason for reporting incidents to
improve patient safety is the belief that safety
can be improved by learning from incidents
and near misses, rather than pretending that
they have not happened
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10. Components
• Data input:
– systems for data input need to be independent
and non-punitive to enhance learning culture
• The data:
– It is vital that the staff are given opportunity to
narrate their own version of events
– Reflect true nature of the incident
– Better chronology of events
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11. • Analysis:
– Requires experts from the speciality, and human
performance (or safety), to work together to
interrogate data and generate meaningful learning
outcomes
– Standardized methodology should be adopted at
this stage
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12. • Feedback:
– Sharing of ideas by all parties involved
– Abandon defensiveness, blame and recriminations
– Goal: learn from mistakes, ensure systems are
improved for better patient safety
– Multiple sources: high-level managerial staff to
the front-end clinical staff
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13. Analyses of Reported Incidents
• Pay attention to psychological and human
factors
• National reporting systems alongside the local
risk management structures
• A standardized framework should be used at
all levels for analysis of the incidents
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14. • Analyse the number and kinds of incidents
• Highlighting the areas for improvement (e.g.
medication errors, retained throat packs)
• Follow up by further actions: raising
awareness, research, audits, training
initiatives, curriculum, and specific guidelines
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15. Components of Incident Analysis
• Identifying the most obvious active failure(s)
– Also known as care management problems (CMP).
These include delayed diagnosis, inadequate
handover, failure to monitor, lack of preoperative
check, protocol violation, incorrect treatment, not
seeking help, inadequate supervision, etc.
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16. • Framing the problem
– Accurate assessment of chronology and the
details of the events leading on to the incident is
important in framing the problem.
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17. • Defining the problem (what, how, and why)
– case notes studies and interviews of the key staff
members
– first determine exactly what happened in terms of
CMPs and chronology of the events.
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18. • next, establish, without being punitive, how it
happened: important acts or omissions made
by staff, and with hindsight the important
chain of events which set up the conditions
for the incident to occur, reasons behind the
acts or omissions
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19. • define why: For each CMP, explore contributory
factors. E.g. lack of knowledge or training at
individual level, unavailability of protocols at task
level, poor communication at team level, inadequate
staffing at organizational level, overstretched staff
rotas, or faulty/incomprehensible guidelines.
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20. • A separate analysis should be carried out for
each CMP using a standardized framework.
• The final analysis will report summary of
chronology, CMPs, and their contributory
causes, and give recommendations for further
actions for each contributory factor
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21. Barriers and Enablers to Incident
Reporting
• Under-reporting, in particular by doctors,
remains a significant problem
• Unfamiliarity with the process
• Cultural issues: fear of punitive action, legal
ramifications, workplace discrimination
• Poor reporting practices by doctors: only bad
doctors make mistakes
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22. Factors Contributing to Successful Error
Reporting
• Flexible and learning culture
• Accept human fallibility
• Training on safety issues
• Annual appraisal
• Establish ground rules: acceptable and
unacceptable behaviour
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23. Factors Contributing to Successful Error
Reporting
• Support / trust / leadership
• Feedback
• Implementing necessary changes
• Consistency
• Clear instructions
• Anonymity
• Confidentiality
• Voluntary
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24. 24
Barriers to Successful Reporting
• Fear of individual / organisational
repercussion
• Defining reportable errors too narrowly
• Workload involved in reporting
• Culture of fear of getting a bad reputation
• No changes with previous reporting
• Uncertainty: differing opinions between right
and wrong

25. Drug Errors
• Definition: error in the prescription, dispensing, or
administration of a medication with the result that
the patient fails to receive the correct drug or the
indicated proper drug dosage
• Drug errors could be inappropriate dosing, wrong
sequence of administration, administration of a drug
different from what was intended, or administration
of a drug which the patient is allergic to
• Commoner during general anaesthesia than during
regional anaesthesia due to the fact that fewer drugs
are used for regional than for general anaesthesia
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26. Webster’s Classification of Drug Errors
Omission: drug not given
Repetition: extra dose of an intended drug
Substitution: incorrect drug instead of the
desired drug; a swap
Insertion: a drug that was not intended to
be given at a particular time or at any time
Incorrect dose: wrong dose of an intended drug
Incorrect route: wrong route of an intended drug
Other: usually a more complex event not fitting the
categories above
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27. Risk Factors for Drug Errors
• Inadequate total experience
• Inadequate familiarity with equipment or
device
• Poor communication with team
• Haste
• Inattention/carelessness
• Fatigue
• Failure to perform normal check
• Lack of supervision
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28. • Inadequate familiarity with surgery
• Inadequate familiarity with anaesthetic technique
• Distraction
• Poor labelling of drugs
• Apprehension
• Demanding or difficult case
• Emergency case
• Boredom
• Insufficient preparation
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29. Consequences of Drug Errors
• Death
• Permanent disability
• Lack of confidence in healthcare organizations
• Litigation
• Guilt
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30. Prevention of Drug Errors
• The label on any drug ampoule or syringe should be read
carefully before the drug is drawn up or injected.
• Legibility and contents of labels on ampoules and syringes
should be optimized according to agreed standards with
respect to font, size, colour and information.
• Syringes should always be labelled
• Double checking of ampoules, syringes and equipment before
starting the procedure
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31. Prevention Cont’d
• Formal organisation of drug drawers and work
space:
– tidiness
– separation of look-alike drugs
– removal of dangerous drugs from the operation room
• Labels should be checked specifically with the
help of a second person or a device like bar code
reader before administration
• Error during administration should be reported
and reviewed
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32. • Management of inventory should focus on
minimising the risk of drug error
• Look-alike packaging and presentation of the
drug should be avoided where possible
• Drug should be presented in prefilled syringes
rather than ampoules
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33. • Drugs should be drawn up and labelled by the
anaesthesia provider himself/herself
• Colour coding by class of drugs should be
according to an agreed national or
international standard
• Coding of syringe according to position or size
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34. Conclusion
• Despite the best efforts, the increased use of
technology and high standards of both
invasive and non-invasive monitoring in
anaesthesia and critical care, medication
errors continue to occur even at the best
centres worldwide.
• Simple vigilance, standardised protocol, and
‘think before act’ are the key factors to avoid
occurrence of medication errors.
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35. References
• Critical incidents and near misses during anesthesia: A prospective audit
Journal of Clinical Sciences
Pamela Onorame Agbamu1, Ifeyinwa Dorothy Menkiti1, Esohe Ivie
Ohuoba1, Ibironke Desalu2
• Critical incident reporting and learning R. P. Mahajan BJA: British Journal
of Anaesthesia, Volume 105, Issue 1, July 2010, Pages 69-
75, https://doi.org/10.1093/bja/aeq133
• Drug Errors and Protocol for Prevention among Anaesthetists in
Nigeria Anesthesiology Research and Practice, vol. 2017, Article ID
2045382, 4 pages, 2017 https://doi.org/10.1155/2017/2045382 U. U.
Johnson, L. N. Ebirim
• Medication error in anaesthesia and critical care: A cause for concern
Indian J Anaesth. 2010 May-Jun; 54(3): 187–192. Dilip Kothari, Suman
Gupta, Chetan Sharma, and Saroj Kothari
• Medication errors in anaesthetic practice: a report of two cases and
review of the literature Afr Health Sci. 2013 Sep; 13(3): 845–849. E Ogboli-
Nwasor https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3824420/
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36. THANK YOU
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