Confirming the drugs administered during anaesthesia: a feasibility study in the pilot National Health Service sites, UK

• Published in: British journal of anaesthesia : BJA Vol. 105; no. 3; pp. 289 - 296
• Main Authors: Evley, R, Russell, J, Mathew, D, Hall, R, Gemmell, L, Mahajan, R.P.
• Format: Journal Article
• Language: English
• Published: Oxford Elsevier Ltd 01.09.2010; Oxford University Press
• Subjects: Anesthesia; Anesthesia - standards; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anesthetics - administration & dosage; Attitude of Health Personnel; Automatic Data Processing; Biological and medical sciences; double-checking; drug administration; drug errors; England; Feasibility Studies; Focus Groups; Humans; Injections, Intravenous; Medical Order Entry Systems; Medical sciences; Medication Errors - prevention & control; Medication Systems, Hospital; patient safety; Pilot Projects; Safety Management - methods; State Medicine - standards; Wales; England; Wales; patient safety; drug administration; double-checking; drug errors; Human; Anesthesia; Feasibility; Health service
• ISSN: 0007-0912; 1471-6771
• DOI: 10.1093/bja/aeq194

To help prevent drug errors, it is recommended that drugs should be confirmed/checked with a second person before administration. We aimed to assess the feasibility of introducing second-person or electronic bar-code confirmation of drugs, administered during anaesthesia, in the National Health Service (NHS) settings in the UK. Seven NHS sites took part in a pilot study over a 3 month period. Five used a second-person and two used bar-code electronic confirmation of drugs given during anaesthesia. A total of 36 consultant anaesthetists and three trainees, 15 operating department practitioners (ODPs), and seven anaesthetic nurses participated. A group of anaesthetists, ODPs, and nurse practitioners (n=11) from different NHS sites independently observed both methodologies. In addition, each site was visited and observed by one of the study investigators. At the end of the study period, four focus groups (two with participants from pilot sites and two with observers) were held. The discussions were taped, transcribed, and qualitatively analysed. Data were triangulated using observer’s notes and investigator’s reflective diaries, and processed using line-by-line coding. The codes were then synthesized into themes. Both methods were perceived to contribute to the prevention of drug errors. For the two-person confirmation to be carried out correctly, there should be no distraction or time pressure. The main limitation to the feasibility was that the continuous presence of the second person was not always possible. The process also met with resistance from the staff at some pilot sites. Electronic confirmation was always feasible, as it did not require the presence of a second person. It was found to be intuitive to the anaesthetist’s current working practice. However, there were some practical issues related to introduction of new technology and an initial learning curve. The introduction of two-person confirmation to the NHS would have a significant impact on the existing working practices. Issues related to resources and a cultural change will need to be addressed. Electronic confirmation was more feasible, but the technological aspects of its integration into the operating theatre environment, and learning, will require further attention.