Misses & near misses: Drug administration errors

Abstract

Background: Mistakes made during administration of drugs to patients can be lethal. In order to analyse these mishaps we need to study the particular circumstances of each accident and define the reasons behind the mistake or lapse. This paper reports the findings of a confidential pilot study designed to highlight the frequency of such unfortunate incidences and formulate recommendations applicable in our society to prevent some of these tragic outcomes. Methods: Sixty doctors and nurses from different hospitals were randomly enquired about the personal knowledge of pharmacological mistakes with which they were either closely associated or they had first hand information of the incident. All data was collected in confidence on condition of anonymity. Results: We discovered 21 instances of drug administration errors. Dispensation of wrong drug to a patient was the commonest mistake discovered. Nurses gave majority of these injections during the night. Half the victims of these mishaps lost their lives. Conclusions: From this confidential inquiry, we have found that tragedies with loss of life are not infrequent in our set up: Typical scenario involved muscle relaxant given instead of narcotic analgesic by a student nurse during the night. When the mistake was not detected in time it frequently ended in tragic loss of life. It is disturbing to note that minimum basic facilities of proper cardiopulmonary resuscitation were not available in some hospitals. Recommendations: Only senior nurses / doctors should give IV injections. Conscious effort should be made to minimise the use of IV medication, drugs should be used only with proper indications when suitable oral alternatives are not feasible. The nurses` training as well as nurse patient ratio needs to be improved. Muscle relaxants should not be available outside operating rooms and critical care units. We need to set up a central confidential data-reporting centre for voluntary (anonymous?) reporting of such mistakes or mishaps so that they could be analysed and concrete preventive measures recommended.