Southern African Journal of Anaesthesia and Analgesia

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Wrong drug administration errors amongst anaesthetists in a South African teaching hospital: research

PC Gordon


A confidential, self-reporting survey was sent out to all 65 anaesthetists (25 specialists and 40 registrars) in the Department of Anaesthesia at the University of Cape Town with the aim of determining the incidence and possible causes of "wrong drug" administrations. The response rate was 95%. 93.5 % of respondents admitted to having administered the wrong drug at some stage of their anaesthetic career. 19/62 (30.6%) have injected the wrong drug or the correct drug into the wrong site on at least three occasions. 56.9 % of incidents involved muscle relaxants with suxamethonium chloride administered instead of fentanyl accounting for nearly a third of cases. 17.6 % of reported incidents were classified as being dangerous, with the potential to cause either severe haemodynamic instability and / or neurological damage or seizures.

SAJAA Vol.10(2) 2004: 7-8
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