Wrong Drug and Wrong Dose – Patient and Doctor Induced Emergencies

00:00 So we're now going to talk about Drug Errors.

00:02 And this mainly means wrong dose, wrong drug, and it's something that happens with anesthesiologists all too commonly. But rarely results in damage to the patient.

00:14 If the anesthesiologist recognizes what drug was given in error, or wrong dose that was given, he or she should be able to adjust rapidly and correct the hemodynamic effects of that inappropriate drug. Drug errors are the most common misadventures suffered by patients in hospitals. This is a worldwide phenomena.

00:38 Huge amount of energy has gone into trying to make this a less frequent event. Current practice requires that all syringes be labeled with the name of the drug and its concentration.

00:50 Drugs in a syringe must never be given to more than one patient, which is something that used to happen fairly frequently. And the use of controlled drugs such as opiates is carefully controlled and monitored. It's hoped that computerized physician entry order systems with built in warnings to advise about possible drug interactions, duplication of orders, wrong doses, or patient allergies to a given medication, will come out automatically when a physician is ordering a drug.

01:26 However, despite these efforts, the commonest errors in hospital continue to be drug errors.

01:32 And I must say that, although it doesn't give me any pride, virtually every anesthesiologist who's been in practice for just a few years is guilty of giving the wrong drug or wrong dose on occasion. If the mistake is recognized, there is rarely an adverse event.

01:50 However, if the anesthesiologist does not recognize the error, or refuses to recognize the error, ignores it, damage to the patient can occur.