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Correspondence |
Chorley, UK
To the Editor:
The editorial by Orser1 on medication safety in anesthetic practice lists 17 recommendations to help reduce the incidence of medication errors. One of these is to "pre-label syringes" (note pleural) before drawing up the drug. I do not think this is a good idea. It is much better to check the ampoule, draw up the drug, recheck the ampoule and then label the syringe. I am aware of an instance of two syringes being pre-labelled ‘fentanyl’ and ‘suxamethonium’ and then the other drug being drawn up, with the suxamethonium administered mistakenly to the patient before fentanyl. This was the only instance in six syringe swaps that the syringes were incorrectly labelled. In four of the other cases the syringes had correct colour coded labels.2,3
However bad a practice it may be, anesthesiologists use visual cues in their day to day work. Induction agents are usually drawn into 10 mL or 20 mL syringes. An antibiotic and albumin have been administered instead of induction agents. A swap has also been reported2,3 between suxamethonium diluted in a 10-mL syringe, to what was described as a convenient concentration for a pediatric patient, and the induction agent. It would seem that the suggestion by Fasting and Gisvold,4 which I too had made earlier,2,3 that one size of syringe be used for one group of drugs should also be one of the recommendations to reduce the incidence of medication errors.
References
1 Orser, BA. Medication safety in anesthetic practice: first do no harm. Can J Anesth 2000; 47: 1051–4.[Medline]
2 Jayasuriya, JP. Breaking the chain of anaesthetic accidents – the use of the incident report technique. Sri Lankan Journal of Anaesthesiology 1995; V: 6–13.
3 Jayasuriya, JP. Syringe drug labels. Anaesthesia 2000; 55: 201–2.
4 Fasting S, Gisvold SE. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anesth 2000; 47: 1060–7.[Abstract]
Toronto, Ontario
Dr. Jayasuriya's comments were appreciated regarding the recommendations to reduce the incidence of medication errors.1 It was suggested that it is inadvisable to pre-label the syringe before drawing up the drug. Although not stated in the recommendations, it is imperative that the labels on the syringe and ampoule are cross-checked before and after drawing up the drug. Since most drugs administered during anesthesia are identical in appearance, it is impossible to identify the contents of the syringe once the drug has been drawn up. Therefore, it is advisable to transfer the drug from one labelled container to another. The window of opportunity for error is opened if the anesthesiologist is distracted after drawing up the drug or if the unlabelled syringe is placed on the drug cart while the label is prepared.
Dr. Jayasuriya raises a second interesting point regarding the value of secondary visual clues such as syringe size to identify groups of drug. Many anesthesiologists, including myself, find these self-designed systems helpful.2 However, secondary identification systems are not standardized and can reduce vigilance. The opportunity for error emerges if two or more anesthesiologists, that use different secondary identification systems, are involved in the same case.
I thank Dr. Jayasuriya for the stimulating comments. Anesthesiologists must continue to discover practical solutions to reduce the likelihood of medication error during anesthesia and contribute to broader efforts to design safer medication delivery systems.
References
1 Orser BA. Medication safety in anesthetic practice: first do no harm. Can J Anesth 2000; 47: 1051–4.
2
Orser BA, Chen RJB, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anesth 2001; 48: 139–46.
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