Medication errors in anesthetic practice in Brazil - an observational study.

Abstract

Introduction: There is increasing data collection in literature on errors in the drug

administration chain. In anesthesiology, emergency and urgency situations favor

errors in medications, however, it is not yet clear how some factors can impact the

frequency of these errors.

Objective: To evaluate the impact of knowledge of important concepts and

fundamentals related to quality and safety in anesthesia in the practice of safe

anesthesia as a factor to prevent errors with medications.

Method: Observational study with participants of the 61st Brazilian Congress of

Anesthesia. The volunteers responded to a semi-structured instrument with issues

related to the whole process that could trigger medication errors.

Results: A total of 337 volunteers (42.2% of Anesthesia Resident Physicians and

57.8% of Anesthesiologists) participated in the study. It was observed that 50.7%

stated that eventually they had already injected wrong medications, with a significant

difference (p <0.00) between the Anesthesia Resident Physicians (43.6%) and

Anesthesiologists (56%). A greater number of working hours and greater number of

hospitals in which they work caused higher percentages of professionals with

medication errors. Among the professionals who reported they had eventually

administered erroneous medications due to confusion with ampoules , 33.8% (n = 54)

of those stated that they made a formal report of the adverse event with medications

(ARP: 24.1% and MA: 39,2%). 96.9% (n = 155) found ampules of different

medications (or concentrations thereof) in the same drug box (ARP) : 93.1%, MA:

99%) and 65.2% stated they have used the same syringe to prepare more than one

anesthetic medication (ARP 75.9%, MA: 59%).

Conclusions: The percentage of medication errors was significant and it is evident

the need to implement policies that will guide the organization, distribution, allocation

and use of medications in the surgical center.