Quarterly Data Summary Issue 11: Learning from reporting - medication incidents in anaesthesia

This learning from reporting section, taken from Quarterly Data Summary Issue 11, focuses on medication incidents in anaesthesia.

Data in the Reporting and Learning System were searched for medication incidents from the specialty of anaesthesia. Incidents were included if they were reported as having occurred between 1 August 2005 and 31 July 2008 and were submitted before 19 November 2008. A total of 1,700 incident reports were extracted and analysed. Virtually all reports came from the acute sector.

The document considers:

• Reported degrees of harm.
• Where incidents happen.
• Incident types.
• Other themes, including failure to label syringes in theatre areas prior to patient transfer to other clinical areas, and non-recording of the type and dose of medication administered in theatre areas.
• Medicines frequently involved in incidents.

Wrong dose, strength or frequency of drugs and incidents occurring during the administration stage are the most frequent incident reports. They are also often linked to the high risk injectable drugs. Improving the quality and level of incident reporting is important to understand risks and strategies needed to improve patient safety.