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October 04, 2020
10/4/2020 3:00:00 PM - 10/4/2020 4:00:00 PM
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Morbidity And Mortality Associated With Drug Administration Errors During Spinal Or Epidural Anesthesia Or Analgesia
Santosh Patel, F.R.C.A.
Tawam Hospital, Al Ain, United Arab Emirates
Disclosures: S. Patel: None.
Background: Aim of this study is to investigate morbidity and mortality associated with drug administration errors during neuraxial anesthesia or analgesia.Methods:Medline database were searched through March 2020 using terms including: “epidural drug error”, “epidural medication error”, “inadvertent epidural drug administration”, “accidental epidural drug administration”. The search was done also using “spinal”, “intrathecal”, and “neuraxial” words in place of epidural. The ‘similar articles’ and ‘related articles’ links were used on PubMed and Google Scholar respectively. Errors via other routes and those related to local anaesthetics and opioid errors were excluded. Drugs involved, clinical consequences and outcome were noted. Reports were divided into groups to know primary source of errors. Morbidity was considered present if clinically undesirable side effect occurred and/or any intervention were necessary to manage. Human factors were summarised using human factors analysis classification system ( Four measures were assessed to prevent errors.1Results:55 drugs were administered inadvertently via neuraxial route in 177 patients (table 1 & 2). 31 drugs were administered in error once only. 60% errors were via epidural route.One third of the errors (59) occurred during obstetric anesthesia or analgesia.19 deaths were reported (table 1 & 2). 13 patients had long lasting residual neurological deficits. 52 patients required tracheal intubation and mechanical ventilation.Multiple patients required haemodynamic and neurological investigations and management. Other frequently reported consequences and measures include abandoning the use of epidural catheter, radiological investigations, neurologist consultations, prolonged ICU and hospital stay and neurological follow up.Ampoules/vials were sources of errors for TA, KCL and digoxin. Syringe swap were common for errors involving NMBDs, induction agents, and antibiotics. Magnesium and paracetamol infusions were involved in Epidural-IV line confusion.Recurrent deficiencies identified using HFACS model include organizational (e.g. purchase of look-alike ampoules, storage issues), supervision (e.g inadequate supervision of anesthesia assistants and residents, unmonitored infusions), precondition of unsafe acts (e.g. fatigue, left over medications) and unsafe acts (e.g. incorrect visual perception, policy violation).Discussion:Principle findings are:1. Several neuraxial drug errors caused significant morbidity. Majority deaths were associated with TA errors. 2. Symptomatic management for morbidity. No scientific and uniform approach. 3. HFACS is useful to identify latent deficiencies.14. All errors are preventable This is the largest drug errors report in the history of neuraxial anesthesia or analgesia. Four measures1 are important for prevention of neuraxial drug errors:1 Careful reading of the label on any drug ampoule or syringe2 Labelling all syringes3 Checking labels with a second person or a device4 Use of non‐Luer connectors on neuraxial devices.Latent failures must be corrected at all four HFACS levels.Reference: Patel S et al. Anaesthesia 2019;74:904-14
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