To meet the WHO vision of reducing medication errors by 50%, it is essential to know the current error rate. We undertook an integrative review of the literature, using a systematic search strategy. We included studies that provided an estimate of error rate (i.e. both numerator and denominator data), regardless of type of study (e.g. RCT or observational study). Under each method type, we categorised the error rate by type, by classification used by the primary studies (e.g. wrong drug, wrong dose, wrong time), and then pooled numerator and denominator data across studies to obtain an aggregate error rate for each method type. We included a total of 30 studies in this review. Of these, two studies were national audit projects containing relevant data, and for 28 studies we identified five discrete method types: retrospective recall (6), self-reporting (7), observational (5), large databases (7), and observing for drug calculation errors (3). Of these 28 studies we included 22 for a numerical analysis and used six to inform a narrative review. Drug error is recalled by ~1 in 5 anaesthetists as something that happened over their career; in self-reports there is an admitted rate of ~1 in 200 anaesthetics. In observed practice, error is seen in almost every anaesthetic. In large databases, drug error constitutes ~10% of anaesthesia incidents reported. Wrong drug or dose form the most common type of error across all five study method types (especially dosing error in paediatric studies). We conclude that medication error is common in anaesthetic practice, although we were uncertain of the precise frequency or extent of harm. Studies concerning medication error are very heterogenous, and we recommend consideration of standardised reporting as in other research domains.

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Despite use of colour-coded labels, syringe substitution (syringe swap) error of anaesthetic drugs remains a frequent and potentially serious cause of iatrogenic harm. We explored the novel concept of using a simple device which can be fitted to existing syringes, and employs colour and raised elements (detents) to provide visual, haptic and auditory cues to supplement the visual cues provided by standard drug labelling, and particularly helps to differentiate, for example, syringes containing vaso-active drugs from other syringes. We produced six different embodiments of the device, and performed a randomised unblinded study with 14 volunteers to identify the functional characteristics which met with the approval of the majority of participants, and the mechanical characteristics which produced adequate haptic feedback without excessive resistance to injection. The optimal design was identified, which required the user to exert a mean (SD) force of ~20 (7) N to overcome the resistance of the detents in the syringe. The majority of volunteers felt that a device of this type would be helpful in reducing the incidence of syringe substitution error; however, further research is needed to assess the efficacy of this innovation in the clinical environment.

The incidence of an anaesthetic drug error can be directly observed in large trials. In an alternative approach, we developed a probabilistic mathematical model in which the anaesthetist is modelled as a \'fallible entity\' who makes repeated drug administration choices during an operation. This fallibility was factored in the model as an initial \'intrinsic error rate\'. The choices faced included: dose; timing of administration; and the routes available for injection (e.g. venous, arterial, epidural, etc.). Additionally, we modelled the effect of fatigue as a factor that magnifies the cumulative error rate. For an initial intrinsic error rate of 1 in 1000 (which from first principles we consider a reasonable estimate), our model predicted a cumulative probability of error over a ~12 h operation of ~10%; that is, 1 in 10 operations this long results in some drug error. This is similar to the rate reported by large observational trials. Serious errors constitute a small fraction of all errors; our model predicts a Poisson distribution for the uncommon serious errors, also consistent with independent observations. Even modest assumptions for the development of fatigue had a dramatic and adverse impact on the cumulative error rate. The practice implications of our modelling include: exercising caution or avoiding starting work if under par; added vigilance in unfamiliar environments; keeping anaesthetic recipes simple; and recognising that operation durations > 5-6 h constitute a time of exaggerated risk. These implications are testable predictions in observational trials. If validated, our model could serve as a potential research tool to investigate the impact of safety interventions on the rate of intrinsic error using simulation.

BACKGROUND: Drug errors are common and can be detrimental to patients, even resulting in death. Junior doctors write most prescriptions and are therefore responsible for most errors. There is little literature about the effect of legibility of the prescriber\'s handwriting on the rate of drug errors. Folklore would deem doctors\' handwriting to be poorer than average; however, studies have shown this to be incorrect. In fact, handwriting in general has been shown to be poor.
METHODS: A random sample of prescriptions from inpatient drug charts were chosen to provide a wide spread of legibility, with an even spread of the use of upper-case and lower-case lettering. Two cohorts of 13 junior doctors and 13 non-medical controls were recruited and asked to transcribe each of the prescriptions. Results were analysed for evidence of a statistical difference in correct transcription rate between lower-case or upper-case letters.
RESULTS: Non-medical participants correctly transcribed only 45% of prescriptions written in lower case. This rose to 66.5% for those written in upper case. This showed strong statistical significance, p<0.005. A statistical difference was also shown for differences in transcription by junior doctors (92.3% vs 97.8%, p=0.016).
CONCLUSIONS: Doctors must take responsibility for the quality of the prescriptions they write, to prevent avoidable drug errors. Legibility is improved by the use of capital letters. Therefore, we recommend that the use of upper cases should become routine practice when writing drug prescriptions.

Drug errors amongst anaesthetists are common. Although there has been previous work on the system factors involved with drug error, there has been little research on the sequelae of a drug error from the anaesthetist\'s perspective. To clarify this issue, we surveyed anaesthetists regarding their most memorable drug error to identify associated factors and personal sequelae regarding their professional practice after the event. An online survey was sent anonymously to 989 Australian and New Zealand College of Anaesthetists (ANZCA) Fellows in March 2016 and the results were collected over the following two months. There were 295 completed surveys (29.8% response). The majority of respondents were male consultants, aged over 45 years. Reported drug errors occurred most frequently during normal working hours, and the most common drugs involved were non-depolarising muscle relaxants. In 34% of the errors, another anaesthetist was present, and their presence was felt to have contributed in 40.7% of these cases. About 20% of respondents reported that they did not receive adequate support after the event. Sleep patterns were affected in 14.4% of respondents, although very few found that the error had affected their capacity to function at work. These findings suggest that memorable drug errors can be significant enough to have adverse sequelae to anaesthetists, even if no patient harm occurs.

BACKGROUND: The neonatal intensive care units (NICUs) are at the highest risk of drug dose error of all hospital wards. NICUs also have the most complicated prescription modalities. The computerization of the prescription process is currently recommended to decrease the risk of preventable adverse drug effects (pADEs) in NICUs. However, Computer Prescribing Order Entry-Clinical Decision Support (C.P.O.E./C.D.S.) systems have been poorly studied in NICUs, and their technical compatibility with neonatal specificities has been limited.
OBJECTIVE: We set up a performance study of the preselected prescription of drugs for neonates, which limited the role of the prescriber to choosing the drugs and their indications.
METHODS: A single 29 bed neonatal ward used this neonatal C.P.O.E./C.D.S. system for all prescriptions of all hospitalized newborns over an 18-month period. The preselected prescription of drugs was based on the indication, gestational age, body weight and post-natal age. The therapeutic protocols were provided by a formulary reference (330 drugs) that had been specifically designed for newborns. The preselected prescription also gave complete information about preparation and administration of drugs by nurses. The prescriber was allowed to modify the preselected prescription but alarms provided warning when the prescription was outside the recommended range. The main clinical characteristics and all items of each line of prescription were stored in a data warehouse, thus enabling this study to take place.
RESULTS: Seven hundred and sixty successive newborns (from 24 to 42 weeks\' gestation) were prescribed 52 392 lines of prescription corresponding to 65 drugs; About 30·4% of neonates had at least one out of licensed prescription; A prescription out of the recommended range for daily dose was recorded for 1·0% of all drug prescriptions. WHAT IS NEW?: The C.P.O.E./C.D.S. systems can currently provide a complete preselected prescription in NICUs according to dose rules, which are specific to newborns and also comply with local specificities (therapeutic protocols and formulation of drugs). The role of the prescriber is limited to the choice of drugs and their indications. The prescriber still retains the possibility of modifying each item of the prescription, with all other prescription items being calculated by the C.P.O.E. system. In these conditions, the prescribers rarely modified the preselected prescription and the rate of out of range prescription was low. A multicentric study is required to confirm and extend these observations.
CONCLUSIONS: This study showed the feasibility of preselected prescription in NICUs and a low rate of out of range prescriptions. The preselected prescription could play a key role in lowering the dose error rate in NICUs.

OBJECTIVE: Medication error can occur due to fault at any level starting from manufacturing until the administration to the patient. It can be difficult to read the drug name and other information from an ampoule, if there is poor contrast between the font color and background of the ampoule. Primary aim of this study was to evaluate the efficacy of the contrast color on the ampoule\'s label.
METHODS: The study was conducted in a randomized blinded manner at a tertiary level trauma center. One hundred and eight resident doctors participated in the study. All the participants were divided into two groups after randomization. Group A was given the original drug ampoule while the modified ampoule with contrast was given to Group B. Total time in reading the ampoule and difficulty in reading (DR) scoring were noted for each participant. Another scoring regarding correct reading of ampoule was also noted and compared.
METHODS: Student\'s t-test and Mann-Whitney test were used accordingly and P < 0.05 was considered as significant.
RESULTS: It was found that mean time taken in reading the original ampoule was more compared to modified ampoule (11.64 ± 1.48 vs. 9.48 ± 1.62 seconds P < 0.05). DR score was also higher in Group A (P < 0.05) and correct reading score was more in Group B (P < 0.05).
CONCLUSIONS: The labels on drug ampoules or vials should always have a contrasting background. This may reduce medication error and improve patient safety.

During labor and child delivery, a wide range of drugs are administered. Most of these medications are high-alert medications, which can cause significant harm to the patient due to its inadvertent use. Errors could be caused due to unfamiliarity with safe dosage ranges, confusion between similar looking drugs, mislabeling of drugs, equipment misuse, or malfunction and communication errors. We report a case of inadvertent infusion of a large dose of magnesium sulphate in a pregnant woman.

Medication error is a major cause of morbidity and mortality in medical profession, and anaesthesia and critical care are no exception to it. Man, medicine, machine and modus operandi are the main contributory factors to it. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.