A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods

Anaesthesia

Volumn 59, Issue 1, 2004, Pages 80-87

  Webster, Craig S ^a,b   Merry, A F ^a,b   Gander, P H ^c   Mann, N K ^a  

^a GREEN LANE HOSPITAL   (New Zealand)

^b UNIVERSITY OF AUCKLAND   (New Zealand)

^c MASSEY UNIVERSITY   (New Zealand)

Author keywords

Anaesthesia; intravenous; Drug labelling; Risk reduction behaviour; Safety

Indexed keywords

ANESTHETIC AGENT; CALCIUM; CEFAZOLIN; EPHEDRINE; FENTANYL; HEPARIN; MAGNESIUM; METARAMINOL; MIDAZOLAM; PANCURONIUM; POTASSIUM; PROPOFOL; PROTAMINE; TRANEXAMIC ACID; VECURONIUM;

ADULT; ANESTHESIA INDUCTION; ANESTHESIST; ARTICLE; BOLUS INJECTION; CLINICAL ARTICLE; CLINICAL EXAMINATION; CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; CONTROLLED STUDY; DRUG ADMINISTRATION ROUTE; DRUG COST; DRUG INFUSION; DRUG LABELING; DRUG SAFETY; ERROR; HEALTH CARE COST; HEART SURGERY; HUMAN; IATROGENIC DISEASE; INJECTION; PROSPECTIVE STUDY; RANDOMIZED CONTROLLED TRIAL; RISK ASSESSMENT; SIMULATOR; SURGICAL TECHNIQUE; SYRINGE; VISUAL ANALOG SCALE;

ADULT; ANESTHETICS, INTRAVENOUS; ATTITUDE OF HEALTH PERSONNEL; CARDIAC SURGICAL PROCEDURES; DRUG COSTS; DRUG DELIVERY SYSTEMS; DRUG LABELING; HUMANS; MEDICATION ERRORS; PROSPECTIVE STUDIES; RISK MANAGEMENT; SYRINGES;

EID: 0347915788     PISSN: 00032409     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1365-2044.2004.03457.x     Document Type: Article

References (41)

1. Ferner RE. Medication errors that have led to manslaughter charges. British Medical Journal 2000; 321: 1212-16.
2. Merry AF, McCall Smith A. Errors, Medicine and the Law. Cambridge: Cambridge University Press, 2001.
3. Institute of Medicine. To Err is Human - Building a Safer Health System. Washington, DC: National Academy Press, 2000.
4. Department of Health. An Organisation with a Memory - Report of an Expert Group on Learning From Adverse Events in the NHS. London: The Stationary Office, 2000.
5. Currie M, Mackay P, Morgan C et al. The 'wrong drug' problem in anaesthesia - An analysis of 2000 incident reports. Anaesthesia and Intensive Care 1993; 21: 596-601.
6. Webster CS. Why anaesthetising a patient is more prone to failure than flying a plane. Anaesthesia 2002; 57: 819-20.
7. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesthesia and Intensive Care 2000; 29: 494-500.
8. Bergman IJ, Kluger MT, Short TG. Awareness during general anaesthesia - A review of 81 cases from the Anaesthetic Incident Monitoring Study. Anaesthesia 2002; 57: 549-56.
9. Kluger MT, Bullock MFM. Recovery room incidents - A review of 419 reports from the Anaesthetic Incident Monitoring Study. Anaesthesia 2002; 57: 1060-6.
10. Reason J. Human error - Models and management. British Medical Journal 2000; 320: 768-70.
11. Perrow C. Normal Accidents - Living with High Risk Technologies. New York: Basic Books, 1984.
12. Sagan SD. The Limits of Safety - Organizations, Accidents, and Nuclear Weapons. Princeton, NJ: Princeton University Press, 1993.
13. Reason J. Managing the Risks of Organisational Accidents. Aldershot: Ashgate, 1997.
14. Berwick DM. Not again! Preventing errors lies in redesign - Not exhortation. British Medical Journal 2001; 322: 247-8.
15. Birks RJS. Safety matters [editorial]. Anaesthesia 2001; 56: 823-4.
16. Carthey J, De Leval MR, Reason JT. Institutional resilience in healthcare systems. Quality in Health Care 2001; 10: 29-32.
17. Reason JT, Carthey J, De Leval MR. Diagnosing 'vulnerable system syndrome' - An essential prerequisite to effective risk management. Quality in Health Care 2001; 10: ii21-5.
18. Merry AF, Webster CS, Mathew DJ. A new, safety-oriented, integrated drug administration and automated anesthesia record system. Anesthesia and Analgesia 2001; 93: 385-90.
19. Takano K, Reason J. Psychological biases affecting human cognitive performance in dynamic operational environments. Journal of Nuclear Science and Technology 1999; 36: 1041-51.
20. Chiles JR. Inviting Disaster - Lessons from the Edge of Technology. New York: Harper Collins, 2001.
21. Merry AF, Webster CS, Weller J, Henderson S, Robinson B. Evaluation in an anaesthetic simulator of a prototype of a new drug administration system designed to reduce error. Anaesthesia 2002; 57: 256-63.
22. Webster CS, Merry AF, Ducat CM. Safety, cost and pre-drawn emergency drugs. Anaesthesia 2001; 56: 818-20.
23. Webster CS, Mathew DJ, Merry AF. Effective labelling is difficult, but safety really does matter. Anaesthesia 2002; 57: 201-2.
24. Anonymous. Standard Specification for User Applied Drug Labels in Anesthesiology (D4774-94). Philadelphia: American Society for Testing and Materials, 1995.
25. Anonymous. Standard for User-Applied Drug Labels in Anaesthesia and Critical Care (Z264.3-98). Etobicoke: Canadian Standards Association, 1998.
26. Anonymous. User-Applied Labels For Use on Syringes Containing Drugs Used During Anaesthesia (AS/NZS 4375). Wellington: Standards New Zealand, 1996.
27. Helmreich RL, Merritt AC. Culture at Work in Aviation and Medicine. Aldershot: Ashgate, 2001.
28. Galletly DC, Rowe WL, Henderson RS. The anaesthetic record - A confidential survey on data omission or modification. Anaesthesia and Intensive Care 1991; 19: 74-8.
29. Lin YC, Miller SR. The impact of price labeling of muscle relaxants on cost consciousness among anesthesiologists. Journal of Clinical Anesthesia 1998; 10: 401-3.
30. Niskanen MM, Ruokonen ET. Association between intraoperative incidents and postoperative outcome and resource utilisation. Anaesthesia 2002; 57: 1052-9.
31. Fraind DB, Slagle JM, Tubbesing VA, Hughes SA, Weinger MB. Reengineering intravenous drug and fluid administration processes in the operating room - Step one: Task analysis of existing processes. Anesthesiology 2002; 97: 139-47.
32. Ducat CM, Merry AF, Webster CS. Attitudes and practices of New Zealand anaesthetists with regard to emergency drugs. Anaesthesia and Intensive Care 2000; 28: 692-7.
33. Stranix ND, Patel A. More painful spikes. Anaesthesia 2000; 55: 412.
34. Palmer J, Ball D. Opening propofol ampoules. Anaesthesia 1998; 53: 416-7.
35. Ali PB. Persistent problem with propofol ampoules. Anaesthesia 1997; 52: 1020.
36. Josefson D. Medical students at risk from needlestick injury. British Medical Journal 1999; 318: 144.
37. Singleton RJ, Ludbrook GL, Webb RK, Fox MAL. Physical injuries and environmental safety in anaesthesia - An analysis of 2000 incident reports. Anaesthesia and Intensive Care 1993; 21: 659-63.
38. Lye ST, Hwang NC. Glass particle contamination - Is it here to stay? Anaesthesia 2003; 58: 93-4.
39. Hutchins E. Cognition in the Wild. Cambridge, MA: Institute of Technology Press, 1999.
40. Naikar N, Sanderson PM. Evaluating design proposals for complex systems with work domain analysis. Human Factors 2001; 43: 529-42.
41. Anonymous. Risk Management (AS/NZS 4360). Wellington: Standards New Zealand, 1999.