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Look-alikes favor emergency drug administration errors: a national survey in Belgium

Errors in drug administration have been identified as a possible cause of serious morbidity or even patient death. Emergency situations increase the chances for human error. The Belgian Society of Anesthesia and Resuscitation (BSAR), the Belgian Society of Emergency and Disaster Medicine (BESEDIM), and The Belgian Society of Intensive Medicine and Emergency Medicine (SIZ) performed a joint survey among 1404 Belgian specialists in these fields about errors in drug administration in their daily practice. Among the 441 responders 64.6% ever drew a drug for another, and 43.5% ever injected one for another (themselves); 96.4% yet experienced such an error, made by themselves or by somebody else; 91.4% said they ever found ampoules in the wrong drawer or box. Among the 89 drugs cited as involved in such errors, the most frequent where atropine (107 times, 24% of responders), adrenaline (94 times, 21%), ephedrine (75 times, 17%), NaCl vs KCl vs aqua pro injectione (17%), xylocaine (11%) and morphine (7%). The major cause of confusing was likeness. Almost everyone involved in a drug error (91.8%) evoked look-alike ampoules (for different drugs), 71.2% look-alike labels and/or packaging, and 56% poor legibility of labels or printing on ampoules. The need to dilute emergency drugs (like inotropes) on the field was cited as a cause of calculation error by 22.9%. Sound-alike names (e.g. epinephrine vs ephedrin, levorenin vs levophed) were also cited. For 23.1%, look-alike i.v. bags containing different solutions caused problem. Among responding MDs 63.5% wore glasses or lenses for one vision impairment, 3% for more than one, and 2% were color-blind.

We conclude that there is an obvious and major problem with legibility of drugs labels, particularly emergency drugs. There is a demand from practitioners to standardize the names, concentrations and designs of emergency drugs. We propose minimal standards or norms to be defined at the European level for emergency drugs, concerning their design, (e.g. pre-diluted drugs in pre-filled ready to use glass syringes), their concentrations, their names, their packaging and labeling, and concerning the legibility of what is printed on ampoules or syringes.

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Baele, P., Aunac, S. & Mols, P. Look-alikes favor emergency drug administration errors: a national survey in Belgium. Crit Care 6, P227 (2002). https://doi.org/10.1186/cc1693

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Keywords

  • Morphine
  • Xylocaine
  • Drug Administration
  • Atropine
  • Aqua