Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

Autor:	Bowdle TA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA. Electronic address: bowdle@u.washington.edu., Jelacic S; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA., Nair B; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA., Togashi K; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA., Caine K; Office of Nursing Research and Department of Biostatistics, University of Washington, Seattle, WA, USA., Bussey L; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA., Kruger C; Department of Cardiothoracic Anaesthesia, Auckland City Hospital, Auckland, New Zealand., Grieve R; Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand., Grieve D; Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand., Webster CS; Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand., Merry AF; Department of Cardiothoracic Anaesthesia, Auckland City Hospital, Auckland, New Zealand; Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand.
Jazyk:	angličtina
Zdroj:	British journal of anaesthesia [Br J Anaesth] 2018 Dec; Vol. 121 (6), pp. 1338-1345. Date of Electronic Publication: 2018 Oct 20.
DOI:	10.1016/j.bja.2018.09.004
Abstrakt:	Background: Anaesthetic medication administration errors are a significant threat to patient safety. In 2002, we began collecting data about the rate and nature of anaesthetic medication errors and implemented a variety of measures to reduce errors. Methods: Facilitated self-reporting of errors was carried out in 2002-2003. Subsequently, a medication safety bundle including 'smart' infusion pumps were implemented. During 2014 facilitated self-reporting commenced again. A barcode-based medication safety system was then implemented and the facilitated self-reporting was continued through 2015. Results: During 2002-2003, a total of 11 709 paper forms were returned. There were 73 reports of errors (0.62% of anaesthetics) and 27 reports of intercepted errors (0.23%). During 2014, 14 572 computerised forms were completed. There were 57 reports of errors (0.39%) and 11 reports of intercepted errors (0.075%). Errors associated with medication infusions were reduced in comparison with those recorded in 2002-2003 (P<0.001). The rate of syringe swap error was also reduced (P=0.001). The reduction in error rate between 2002-2003 and 2014 was statistically significant (P=0.0076 and P=0.001 for errors and intercepted errors, respectively). From December 2014 through December 2015, 24 264 computerised forms were completed after implementation of a barcode-based medication safety system. There were 56 reports of errors (0.23%) and six reports of intercepted errors (0.025%). Vial swap errors in 2014-2015 were significantly reduced compared with those in 2014 (P=0.004). The reduction in error rate after implementation of the barcode-based medication safety system was statistically significant (P=0.0045 and P=0.021 for errors and intercepted errors, respectively). Conclusions: Reforms intended to reduce medication errors were associated with substantial improvement. (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)
Databáze:	MEDLINE
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