Drug administration errors in anaesthesia and beyond

No anaesthetist will complete a career without encountering a drug error. For each anaesthetic procedure performed, the risk of such an error occurring is 0.01-0.75%.1 Drug errors in anaesthesia are mainly errors of drug administration because, except for preoperative or postoperative care, anaesthetists do not prescribe drugs. In operating theatres, they select, prepare, label, and administer all the drugs needed for the procedure. As a result, commonly known strategies to minimise errors in the prescription of drugs in hospitals, such as computerised physician order entry and decision support systems, are of little use in anaesthesia.2

In the linked study (doi:10.1136/bmj.d5543), Merry and colleagues test a new system designed to tackle this problem.3 Their randomised trial on more than 1075 anaesthetised patients compared a new multimodal system they developed with conventional drug administration. The new system was based on the best evidence based practices designed to minimise administration errors,4 and …