Safety issues in anaesthesia have been discussed informally for some time now and in recent years safety in relation to medicine in general has become topical [
One of the biggest risks in anaesthetic practice is the administration of drugs most of which are given intravenously. Anaesthetists have the unique responsibility to prescribe and administer potent drugs, usually in rapid sequence [
Medication errors are common in all areas of clinical practice. The National Coordinating Council for Medication Errors Reporting and Prevention [
The prevalence of medication errors in anaesthetic practice in Ghana is not known as there are no laid down mechanisms for reporting or tracking down such errors. This study was therefore carried out to find the prevalence of medication errors among the Physician-Assistants Anaesthesia (P-A A) members who work in various parts of the country. This group was chosen because they provide about 80% of anaesthesia in the country.
The study was approved by the Committee on Human Research Publication and Ethics, School of Medical Sciences, Kwame Nkrumah University of Science and Technology. A questionnaire was administered to the P-A A who attended the 13th Update in Anaesthesia conference in Kumasi from 16 to 17 April 2013. The questionnaires were collected before the end of the conference.
IBM SPSS Statistics software version 20 was used in the data analysis. Demographic characteristics of respondents were identified and analysed. Results were summarized as mean and standard deviations for numerical variables, frequencies, and percentages for categorical variables. Chi-square tests of association and Fisher’s exact test were performed to study the association between potential risk factors contributing to medication errors, outcome of medication error, period of occurrences, time of the day, and type of medication error. Suggested measures needed for the prevention of medication errors were presented on a frequency table.
Of the 220 registered participants, 164 (74.6%) completed the questionnaire. There were a number of questions which were not filled in by the respondents. For example, the sex was indicated by 148 respondents of whom 92 (62.2%) were males and 56 (37.9) were females. The mean age was 38.3 years (SD 9.4) The details of the hospital type where they practiced, the practice duration, and the number of refresher courses attended in previous years are shown in Table
Demographic characteristics of Physician-Assistants Anaesthesia.
Characteristics | Mean (SD) | Frequency, |
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Age | 38.3 (9.4) | |
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Sex |
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Male | 92 (62.2) | |
Female | 56 (37.8) | |
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Hospital type† | ||
Government | 109 (66.5) | |
Mission | 38 (23.2) | |
Private | 8 (4.9) | |
Quasi-government | 3 (1.8) | |
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Practice duration‡ | ||
<2 yrs | 32 (20.1) | |
2–5 yrs | 65 (40.9) | |
6–10 yrs | 29 (18.2) | |
>10 yrs | 33 (20.8) | |
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Number of refresher courses attended in the past years† | ||
1-2 | 50 (31.6) | |
3-4 | 59 (37.3) | |
5-6 | 18 (11.4) | |
>6 | 31 (19.6) |
Total number of participants = 164;
One hundred and seven (65.2%) of the respondents had experienced a medication error in their practice out of whom 101 (94.4%) have had it one to five times. Most of the episodes occurred in the afternoon (42.5%) or in the night (26.4%), the two periods constituting nearly 70%.
When asked about the details of the medication errors, 105 out of 107 answered this section. The administration of the wrong drug was reported by 76 (72.4%). Even though there was no harm done in 64 of the patients, with minor or moderate harm in nine other patients, there were three deaths. Unfortunately, the name(s) of the wrong drugs were not ascertained. The outcomes of the errors due to wrong dose, wrong dilution, and wrong route are as shown in Table
Nature of medication errors.
Medication error, |
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Wrong drug | Wrong dose | Wrong dilution | Wrong route | Total (%) | |
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No harm | 64 | 13 | 6 | 6 | 89 (84.8) |
Minor harm | 6 | 3 | Nil | Nil | 9 (8.6) |
Moderate harm | 3 | Nil | Nil | Nil | 3 (2.9) |
Severe harm | Nil | 1 | Nil | Nil | 1 ( |
Death | 3 | Nil | Nil | Nil | 3 (2.86) |
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76 (72.4) | 17 (16.2) | 6 (5.7) | 6 (5.7) | 105 (100) |
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Preinduction | 13 | 1 | 1 | 4 | 19 (18.1) |
At induction | 15 | 5 | 2 | Nil | 22 (20.9) |
Intraoperation | 43 | 10 | 3 | 1 | 57 (54.3) |
Postoperation | 4 | 2 | Nil | 1 | 7 (6.7) |
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75 (71.4) | 18 (17.1) | 6 (5.7) | 6 (5.7) | 105 (100) |
Only 92 (86%) out of the 107 respondents who reported medication error answered the section on the contributing factors. The greatest contributing factor was familiarity with vial/ampoule colour at 37%. This was followed by tiredness (32.6%) and distraction (19.6%). There is a statistically significant association between medication error and factors contributing to medication errors (
Factors contributing to medication error.
Medication error, |
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Wrong drug | Wrong dose | Wrong dilution | Wrong route | Total (%) | |
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Distraction | 10 | 4 | 2 | 2 | 18 (19.6) |
Tiredness | 22 | 6 | Nil | 2 | 30 (32.6) |
Health | 2 | Nil | Nil | Nil | 2 (2.2) |
Poor illumination | 4 | Nil | Nil | Nil | 4 (4.4) |
Familiarity with vial/ampoules colour | 29 | 2 | 2 | 1 | 34 (37) |
Social problems | 1 | Nil | Nil | Nil | 1 (1.1) |
Others†† | 3 | Nil | Nil | Nil | 3 (3.3) |
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71 (77.2) | 12 ( |
4 (4.4) | 5 (5.4) | 92 (100) |
††Other contributing factors include lack of vigilance, late labelling of drug, lack of assistance, oxygen administration error, complaints from patient, poor colouration of ampoules, poor labelling of drug, and pressure from doing a lot of cases.
Forty-five (43%) of the errors occurred in the afternoon followed by 33 (31%) in the morning with the night having the least of 27 (25%).
Nonphysician anaesthesia providers run the shift system with the morning shift running from 8 a.m. to 2 p.m., the afternoon shift from 2 p.m. to 8 p.m., and the night shift from 8 p.m. to 8 a.m. The least number of medication errors occurring in the night may be due to the fact that few cases are done during the night.
Regarding the question on the suggested measures to be put in place to prevent medication errors, a number of suggestions were made by the respondents. These can be divided into two main categories: strengthening of the system or structures and improvement in the anaesthetic practice. In the first category were the involvements of anaesthetist in the purchase of anaesthetic drugs, the provision of assistance, and drug labels. In the second category were checking and rechecking of dugs if possible with another person, labelling of drugs soon after drawing, and discarding of all drugs unused at the end of the day.
The medication error of 65.2% reported in this study clearly shows that medication error is not uncommon in Ghana. This figure is however lower than the 85% reported from Canada [
Medication error in anaesthesia has been estimated at 1 : 133 [
Medication errors have been reported from other countries [
The administration of wrong drug was about 72% of the errors reported in this study. We did not ask about the particular drugs that were involved. All the drugs used in anaesthetic practice have been implicated [
Some of the factors contributing to the administration of wrong drugs were identified in this study. Similarity of the vial/ampoule colour was cited by 37% of the respondents. Atropine and adrenaline are often presented in 1 mL amber coloured ampoules in Ghana. The probability of adrenaline being given instead of atropine is therefore high if care is not taken.
In Llewellyn et al.’s study [
Tiredness was the second most important factor contributing to medication error. Some of the hospitals in Ghana have one or two P-A A who do both elective and emergency operations. The highest percentage of operations done in these hospitals is obstetric cases. The relationship between fatigue and medication error has been documented from Australia [
The wrong dose given to patients could be due to the wrong estimation of the weight of the patients or the wrong dilution of the stock solution such as sodium thiopentone which can be presented as 1 gm vial instead of 0.5 gm.
Distraction in the theatre accounted for 19.6% of the errors. Distraction in theatres is not uncommon, some of which can be considered “legitimate” such as the communication between the anaesthetist and the surgeon. The timing of this “legitimate” distraction can have a serious impact on patient safety. Distraction led to the administration of the wrong drug and the use of wrong route. Other forms of distraction in modern theatres are from cell phones. The pitch of the ringing tone is usually loud and causes a lot of distraction. Cell phones can be put on vibration or silent mode during operations. Unnecessary movements of personnel in and out of the theatres can also cause distraction.
In an editorial by Smith and Mahajan, distraction was implicated in critical incidence development during anaesthesia [
Pressure from work overload, the late labelling of drugs, and the lack of assistance in the form of anaesthetic technician were additional factors contributing to medication errors. As indicated earlier, a number of these P-A A are working alone and are under constant pressure from the medical personnel, who are usually the head of the hospital, to do more cases.
Medication errors were recorded throughout the various stages of anaesthesia, from induction to the postoperative period. The highest incidence of 54.3% occurred during the maintenance of anaesthesia as compared to 21% at induction. This is similar to that of Mahajan [
Nearly 43% of the errors occurred in the afternoon as compared to 31% in the morning. This is not unexpected as fatigue could have set in by the afternoon because the same anaesthetist usually continues till the afternoon. The lowest incidence of 26% at night could be due to a change in personnel for the night shift.
Anaesthetic practice has progressed from the use of different syringe sizes to indicate the class of drugs to the use of markers to label syringes to the present situation where internationally accepted colour coding for drugs is being used in some countries. However, most hospitals in Ghana use the marker to label syringes. In Gordon and colleagues’ study [
Colour coding for syringes does not absolve the user for correctly identifying the drug before drawing it. There is still a possibility that a wrong drug will be drawn instead of the intended one and the “correct” label will be put on it. Wildsmith [
Another potential source of danger is the manner in which anaesthetic drugs are stored in theatre. Drugs with completely different actions are packed next to each other [
The effect of these medication errors on the physiological parameters of the patient depends on the type of drug given. Changes in heart and blood pressure as well as apnoea and paralysis have all been reported [
Medication errors lead to increased cost of care to the hospital. Studies from the United States give an idea of the cost implication. These medication errors caused one teaching hospital $5.6 million [
This study has shown that majority of anaesthesia providers in Ghana who completed this survey reported that they made an error or more in their practice. Even though the majority of the patients did not suffer any harm, the three deaths reported are considered avoidable. The Chinese proverb “the error of one moment becomes the sorrow of a whole [
The authors declare that they have no financial or personal relationship which may have inappropriately influenced them in writing this paper.
The authors acknowledge the help of all the P-A A who filled in the questionnaires.