Recurrent wrong-route drug error - a professional shame

Errors in medicine administration: how can they be minimised?

Errors in medicine administration often go unnoticed and unreported. This article describes three medicine-related errors and provides recommendations to reduce risk. All medicine-related errors should be reported locally and to the National Patient Safety Agency (NPSA) so that they can be collated and trends identified. Electronic prescribing and patient/medicine identification by bar codes, double checking and using colour coded syringes for intravenous and enteral administration, employing more clinical pharmacists and regular education may reduce medicine-related errors.

Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System

The incident reporting database at the National Patient Safety Agency was interrogated on the nature, frequency and severity of incidents related to anaesthesia. Of 12,606 reports over a 2-year period, 2842 (22.5%) resulted in little harm or a moderate degree of harm, and 269 (2.1%) resulted in severe harm or death, with procedure or treatment problems generating the highest risk. One thousand and thirty-five incidents (8%) related to pre-operative assessment, with harm occurring in 275 (26.6%), and 552 (4.4%) related to epidural anaesthesia, with harm reported in 198 (35.9%). Fifty-eight occurrences of anaesthetic awareness were also examined. This preliminary analysis is not authoritative enough to warrant widespread changes of practice, but justifies future collaborative approaches to reduce the potential for harm and improve the submission, collection and analysis of incident reports. Practitioners, departments and professional bodies should consider how the information can be used to promote patient safety and their own defensibility.