Cheese, drug labels and anaesthetic room error

A recent editorial and correspondence over several years draw attention to drug labelling and its importance in the avoidance of drug error in the anaesthetic room [1–4]. Labelling of the packaging, ampoule and syringe are important but not unique factors in anaesthetic room drug error. It is of concern that whilst other areas of error in medicine undergo vigorous systems analysis, we seem to be looking no further than the issue of labelling – if we could only get the label right, we would never make a drug error. The mechanisms of cognition and of cognitive error are well described elsewhere [5, 6]. Should we not take a more analytical approach to this problem rather than the simplistic one that discussions about drug labelling seem to invite? Giving drugs in the anaesthetic room is a classic example of latent error. We have been set up. What other group of health professionals prescribe, dispense and administer potentially lethal drugs to patients we may have met only minutes before without any system of checking? Errors are going to happen no matter how careful we are. In the past we may have been slow to implement change, as one single change was not going to make the system perfect. Now, with understanding of the ‘Swiss Cheese’ phenomena, it is apparent that we must take every step possible, no matter how small, to make the system as good as we possibly can whilst accepting that perfection is unlikely in a system that relies to any extent upon individuals reading drug labels. The drawing up of drugs is an example of a skill-based action, which as such is governed by patterns of preprogrammed instructions (schemata) that is largely subconscious. Skill based errors are known as slips – they are unintended actions. There are several factors, both endogenous and exogenous, that make slips more likely and could be avoided [5]. Fatigue, sleep loss, alcohol, drugs and illness are examples of endogenous factors that are thought to make slips more likely and are under the control of the individual. Exogenous factors are more difficult for the individual to control. Overwork and stress are all emotions we are familiar with, but should we really be rushing to get an over-optimistic list finished? The environment in the anaesthetic room is important. The temperature should be appropriate for both you and the patient. Noise should be kept to a minimum and interruptions not allowed. Fear and anxiety are good for you in moderation, but excess results in under-performance. They normally arise when undertaking occasional practice or working in an unfamiliar environment. Departments should not allow this to happen. It is important that we, as individuals, realise that when we are angry we are more likely to make a mistake. Boredom should be avoided, and breaks during long cases facilitated. Many of us have developed patterns of work that we consider to be safe practice. Some are common sense, others more controversial. We should share this information, encourage debate and re-examine our own practice. For example, what practical steps can be taken to avoid drug error in the anaesthetic room? The standardisation of anaesthetic room drug cupboards is a first step, removing those drugs that are not often used and keeping drug stock centrally to avoid crowded cupboards. Only the drugs in use specifically for that list should be removed from that cupboard by the anaesthetist and placed on the work surface. Drugs would be kept alphabetically, with no labels on the shelf. No individual ampoule should ever be put back into a box, and they should not be removed from the packaging and kept elsewhere. Ampoules should be for single use only and not left open on the bench. When a supplier for a particular drug is changed, each individual anaesthetist should be informed and warning labels attached to the drug boxes. It has been assumed that best practice is that the anaesthetist who is going to administer the drugs should draw them up. Perhaps the Operating Department Assistant should draw them up and we check them? The diluting of drugs is a potential source of error. The commonest slip is giving a wrong drug but in the right sized syringe [7]. Should we draw all induction agents up into a 20-ml syringe, all neuromuscular blocking drugs into a 5-ml syringe and all analgesics into a 2-ml syringe? If local anaesthetic is to be used, it should be drawn up and used before the induction agent is drawn up. Conversely, if the block is to be performed after induction, draw the local anaesthetic up only once the patient is asleep. These suggestions ignore the issues that surround labelling, and individually will not prevent drug error. However, taken together, they may work synergistically to make error much less likely. Anaesthetic department practice, pharmacy policy, theatre management, the physical environment we work in and our own well being all play a role in anaesthetic room drug error. Until we accept the multifactorial causes of these errors, they will continue to happen with alarming frequency and potential for disaster.