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Detection and Prevention of Incidents Related to Drugs

  • KIUCHI Riko
    Department of Anesthesiology, Faculty of Medicine, University of Yamanashi
  • ISHIYAMA Tadahiko
    Department of Anesthesiology, Faculty of Medicine, University of Yamanashi
  • OGUCHI Takeshi
    Department of Anesthesiology, Faculty of Medicine, University of Yamanashi
  • KASHIMOTO Satoshi
    Department of Anesthesiology, Faculty of Medicine, University of Yamanashi
  • MATSUKAWA Takashi
    Department of Anesthesiology, Faculty of Medicine, University of Yamanashi

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Other Title
  • 薬剤関連インシデントとその対策および効果についての検討

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Abstract

  Incident reports have been a major source of information in the development of errors in clinical anesthesia. In the past eight years, 276 incidents were reported in our department. Errors associated with drugs and ventilation accounted for 46% of all incidents. We therefore summarized and highlighted drug-related incidents, which occurred from January 1999 to August 2006. We also evaluated the preventive strategies for drug mishaps. Because administration of the wrong drug was the major factor in drug-related incidents, we introduced labels that were pasted on the syringes. Afterwards, incidents associated with drugs decreased but did not decline to zero. We then made the drug-handling manual. In the manual, when anesthesiologists want to administer a drug, they have to consult their supervisor as to whether the drug is appropriate. After introducing the manual, inadvertent drug mishaps decreased and only one case was reported in 2006. Using labeled syringes is not sufficient for preventing wrong drug administration. Checking drugs by more than 2 anesthesiologists should be an efficient strategy for minimizing drug-related mishaps.

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