THE WRONG DRUG-PROBLEM IN ANESTHESIA - AN ANALYSIS OF 2000 INCIDENT REPORTS

Amongst the first 2000 incidents reported to the Australian Incident M onitoring Study, there were 144 incidents in which the ''wrong drug'' was nearly or actually administered to a patient. Thirty-three percent of the incidents involved ampoules and just over 40% syringes; in ove r half of the latter the syringes were of the same size, and also, in over half, they were correctly labelled In 81% of the 144 incidents th e ''wrong drug'' was actually given. This was more common with syringe s (93%) than ampoules (58%). Thus the most common error was actually g iving the wrong drug from a correctly labelled syringe. The most commo n drug involved was a muscle relaxant in both ampoule and syringe inci dents. In 74% of all reports, there was the potential for serious harm to the patient, however no deaths were reported. Factors which contri buted significantly to the incidents were similar appearance, inattent ion and haste. ''Failure of communication'' was a significant factor i n syringe incidents when two or more staff were involved. The only sig nificant factor which minimised the outcome was rechecking of the syri nge or drug ampoule before giving the drug. Strategies suggested to ad dress the ''wrong drug'' problem include education of staff about the nature of the problem and the mechanisms involved; colour coding of se lected drug classes for both ampoules and syringes, the use of standar dised drug storage, layout and selection protocols; having a drawing u p and labelling convention, and the use of checking protocols.