Drug errors in anaesthesia: technology, systems and culture

Evley, Rachel S. (2011) Drug errors in anaesthesia: technology, systems and culture. PhD thesis, University of Nottingham.

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Annually in Britain, iatrogenic harm results in patient deaths, increased morbidity, and millions of pounds spent on additional healthcare. Errors in the administration of drugs have been identified as a leading cause of patient harm in major international reports,1 2 and the literature also suggests that most practicing anaesthetists have experienced at least one drug error.34

Methods of conventional drug administration in anaesthesia are idiosyncratic, relatively error prone, and make little use of technology to support manual checking. While there is support for the use of double-checking during anaesthesia practice, the availability of a second person during every drug administration, and issues around hierarchy and recognised automaticity in checking 5 can potentially be the limitations. Currently there has been little work carried out in the UK in relation to the use of double checking protocols and there remains a need for a robust check that can be implemented within the National Health Service (NHS).

The first study explored the feasibility of introducing a double check methodology, either second-person confirmation or electronic confirmation into clinical practice within the NHS. This was the first study of this nature within the NHS and explored the attitudes, barriers and benefits of each method.

The second study was designed to explore the beliefs and attitudes of anaesthetists and Operating Department Practitioners (ODPs) on introducing technology which is designed to reduce drug error. This study also explored in greater depth the culture issues raised in the first study and the impact of introducing the electronic confirmation on the anaesthetist’s workload.

The findings suggested that while many participants acknowledged that the process of second person double checking was an important factor to minimise the opportunity of any unsafe medication administration, the process of second person confirmation could be prone to human manipulation and could alter the behaviour and practice of the anaesthetist, resulting in a reluctance to adopt it.

The electronic confirmation method was found to be more feasible. It did not rely on the presence of a second person at the time of drug administration, and did not impact on the anaesthetist’s workload.

This thesis has shown that technology was more readily accepted and seen as more feasible to use by anaesthetists within their clinical practice. However, these studies have also shown that the culture and beliefs of the organisation and individuals, in particular of ‘blame and shame’, has such a strong influence that it continues to prevent a true safety culture developing into an open culture of reporting incidents, recognising that drug errors remain a problem, and that corrective measures are required to prevent them.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Mahajan, R.P.
Hardman, J.G.
Keywords: Qualitative, Patient Safety, Drug Error, Observation, Focus Group, Interview, Grounded Theory, Anaesthesia
Subjects: W Medicine and related subjects (NLM Classification) > WO Surgery
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Clinical Sciences
Item ID: 12163
Depositing User: EP, Services
Date Deposited: 30 Mar 2012 09:51
Last Modified: 15 Dec 2017 08:40
URI: https://eprints.nottingham.ac.uk/id/eprint/12163

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