Research
Proven Reduction in Anesthetic Drug Error
In 2006 a milestone clinical study was presented at the American Society for Anesthesiology demonstrating a statistically significant reduction in bolus to bolus drug error of 40.7%. This is the patient safety premise upon which the SAFERsleep System is developed. ix
Incidence of Drug Error
Human error is a significant problem in modern healthcare, harming patients and increasing costs. i, ii, iii
A prospective study of 10,806 anesthetics found a drug error of some kind occurred in 1 out of 133 anesthetics. iv
In 2005 a review into the nature of anesthetic incidents found that more than 50% involved syringe and/ or drug preparation error. v
Impact of Drug Error
This 2005 study found the overall impact of anesthetic incidents included:
- 11.7% minor morbidity.
- 4.7% major morbidity (0.3% died).
- 4.4% experienced awareness.
- 2.2% had an unplanned visit to ICU.
- 2.8% had a prolonged stay in hospital.
Research has also shown that conventional anesthetic records are often unreliable, contributing to anesthetic incidents. vi
Drug Error Prevention
A systematic review of the error-prevention literature in anesthesia identified the following strategies:
- Carefully check vial/ ampoule before drawing up or administering drug.
- Optimize syringe label legibility and apply standards, e.g. class color.
- Syringes should be labeled.
- Formal, orderly organization of drug drawers and workspace. Manage proximity of similar and dangerous drugs.
- Second person should validate drug before drawing up or administering.
Improved Capture of Administered Drugs
Clinical use of the SAFERsleep System demonstrated a 21.7% increased capture of drug administration during an anesthetic compared with traditional handwritten recordes. This improved accuracy enables improved drug inventory and utilization data and facilitates more accurate patient billing. x
Safer Sleep Drug Safety Research
Safer Sleep’s safety solutions were pioneered in New Zealand by Professor Alan Merry, Chair of the Department of Anaesthesiology at the University of Auckland.
Dr. Merry’s group has been recognized as “world leaders in the analysis of medication errors and in devising methods to try and decrease their occurrence.vii The SAFERsleep System solution is the result of the group’s research and is designed to support the activities described in Drug Error Prevention.
Ongoing research by this team continues to guide the development of the SAFERsleep System. Read More…
i Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. New England Journal of Medicine 1991; 324: 370-6.
ii Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian health care study. Medical Journal of Australia 1995; 163: 458-71.
iii Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
iv Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesthesia and Intensive Care 2001; 29: 494-500.
v Abeysekra A, Bergman IJ, Kluger MT, Short TG. Drug error in anesthesia practice: a review of 896 incidents from the Australian Incident Monitoring Study database. Anaesthesia 2005; 60: 220-7.
vi Galletly DC, Rowe WL, Henderson RS. The anaesthetic record: a confidential survey on data omission or modification. Anaesthesia and Intensive Care 1991; 19: 74-8.
vii Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidence-based strategies for preventing drug administration error during anaesthesia. Anaesthesia 2004; 59: 493-504.
viii Woods I, Clinical Specialty Advisor, National Patient Safety Agency; Editorial, Making Errors: admitting them and learning from them. Anaesthesia 2005; 60: 215-9.
ix Merry AF, Webster CS, Larssen L, Wells J, Fryben C. Prospective Assessment of a new anaesthetic drug administration system designed to improve safety. Anesthesiology 2006;106:A138.
x Nolan A, Rhodes WD. Implementing a Barcoded Anesthetic System for Improved Documentation and Patient Safety. Pharmacy Purchasing and Products April 2007, Vol 4 Number 4.
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