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Crisis management during anaesthesia: problems associated with drug administration during anaesthesia

¹ Consultant Anaesthetist, Princess Royal University Hospital, Orpington, Kent, UK
² Anaesthetic Registered Nurse, Royal Adelaide Hospital, Adelaide, South Australia, Australia
³ Professor and Head, Department of Anaesthesia and Intensive Care, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
⁴ Consultant Specialist, Australian Patient Safety Foundation and Visiting Research Fellow, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia

Correspondence to:
Professor W B Runciman
President, Australian Patient Safety Foundation, GPO Box 400, Adelaide, South Australia 5001, Australia; research{at}apsf.net.au Background: Modern anaesthetic practice relies upon the administration of a wide range of potent drugs given by a variety of routes, at times in haste or under conditions of stress. Problems associated with drug administration make up the largest group of incidents reported during anaesthesia, with outcomes including major morbidity and death. It was decided to examine the role of a structured approach to the diagnosis and management of drug problems under anaesthesia.

Objectives: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK", supplemented by a specific sub-algorithm for drug problems, in the detection and management of drug problems occurring in association with anaesthesia.

Methods: The potential performance of this structured approach for the relevant incidents among the first 4000 incidents reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual performances as reported by the anaesthetists involved.

Results: Among the first 4000 reports received by AIMS there were 1199 reports which detailed 1361 incidents involving the use of drugs. Contributing factors named included errors of judgement (20%), lack of attention (17%), and drugs deemed to have been given in haste. Major morbidity or prolonged stay ensued in over one quarter of reports and 15 patients (1.25%) died. Drug overdose, side effects, and allergic reactions accounted for the majority of serious outcomes.

Conclusion: It was judged that the use of the COVER–ABCD algorithm during the course of an anaesthetic, properly applied, would prevent many drug related incidents from occurring. The sub-algorithm presented here provides a systematic framework for detecting the causes of drug related incidents.

Keywords: anaesthesia complications; drug errors; drug interaction; crisis management; side effect

Relevant Article

Crises in clinical care: an approach to management

W B Runciman and A F Merry
Qual. Saf. Health Care 2005 14: 156-163. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

				W B Runciman, M T Kluger, R W Morris, A D Paix, L M Watterson, and R K Webb Crisis management during anaesthesia: the development of an anaesthetic crisis management manual Qual. Saf. Health Care, June 1, 2005; 14(3): e1 - e1. [Abstract] [Full Text] [PDF]