PHEA human factors

No abstract text is available yet for this article.

Despite use of colour-coded labels, syringe substitution (syringe swap) error of anaesthetic drugs remains a frequent and potentially serious cause of iatrogenic harm. We explored the novel concept of using a simple device which can be fitted to existing syringes, and employs colour and raised elements (detents) to provide visual, haptic and auditory cues to supplement the visual cues provided by standard drug labelling, and particularly helps to differentiate, for example, syringes containing vaso-active drugs from other syringes...

INTRODUCTION: Medication errors are a preventable cause of patient injury. In May 2003, as a result of a joint initiative by the Royal College of Anaesthetists, the Association of Anaesthetists of Great Britain and Ireland, the Intercollegiate Faculty of Accident and Emergency Medicine and the Intensive Care Society, a new colour code chart for syringe labelling was introduced. The introduction of the new system has not been uniform in the Irish Republic with no national guidelines or time scale in place...

BACKGROUND AND OBJECTIVES: The potential for increased drug administration errors during the transition to the International Colour Coding syringe labelling system has been highlighted. The purpose of this study was to assess the potential effects before their introduction into our department. METHODS: Thirty-one anaesthetists, 19 with no previous practical experience of the new labelling system (Group 1), and 12 with previous experience (Group 2), volunteered to induce general anaesthesia for a standardized simulated patient in a designated theatre...

We conducted a postal survey of lead obstetric anaesthetists in all consultant-led maternity units in the UK about drug errors and the measures taken to reduce or prevent them. Of the 179 out of 240 (75%) who responded, 70 (39%) knew of at least one drug error in their unit during the last year, with 28 of them (40%) experiencing more than one. Of the most recent errors, giving the wrong drug (most commonly thiopental instead of antibiotics or vice versa [14 cases], or suxamethonium instead of [Formula: see text] [8 cases] or other drugs [4 cases]) was the most common error, occurring in 27 units (15%)...

PURPOSE: The objectives of this study were to determine: 1) if anesthesiologists had experienced a medication error and 2) to identify causal factors. The perceived value of a Canadian reporting agency for medication errors and improved standards for labels on drug ampoules was also investigated. METHODS: A self-reporting survey was mailed to members of the Canadian Anesthesiologists' Society (n = 2,266). Respondents provided free-text descriptions of medication errors and answered fixed response questions...

PURPOSE: To describe the frequency and pattern of drug errors in clinical anesthesia, and to evaluate whether a change to colour coded syringe labels, along with education, could reduce the problem of drug errors. METHODS: We prospectively recorded anesthesia-related information from all anesthetic cases for 36 mo, totally 55,426 procedures. Intraoperative problems, including drug errors, were recorded. After eighteen months we changed to colour coded syringe labels, and the effect of this change and education on drug errors was assessed...