Incidence and Impact of Drug Error

Human error is a significant problem in modern healthcare, harming patients and increasing costs. Ref 1, 2, 3 A prospective study of 10,806 anaesthetics published in 2001 found a drug error of some kind occurred in 1 out of 133 anaesthetics. Ref 4. Such an error rate can mean that every anaesthetist can expect to harm Ref 2 patients through drug administration error during the course of their career.

A recent report from the UK’s National Reporting and Learning System  Ref 11 emphasised the importance of engaging the key speciality groups involved with generating incidents in the process of reporting them. Their analysis of 2000 incidents related to anaesthesia found that many patients had been harmed, but was unable to identify any recommendations to reduce the likelihood of the same things happening again because of inadequate detail about the specifics of what had gone wrong, and why.

In 2005, an review into the nature of 896 drug errors during anaesthetic found that more than 50% involved syringe and/or drug preparation errors. Ref 5 The outcomes of these incidents included:

• 11.7% minor morbidity.
• 4.7% major morbidity (0.3% died).
• 4.4% patient awareness under anaesthesia.
• 2.2% had an unplanned admission to ICU.
• 2.8% had a prolonged hospital stay.