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May 1997
Volume 61 |
Number 5
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| ASA Releases Patient
Safety Videotape No. 26 on Drug Errors |
Ellison C. Pierce, Jr., M.D., Executive Producer
ASA Patient Safety Videotape Series
The newest videotape in the ASA Patient Safety Videotape Series,
"Drug Errors in Anesthesia," Videotape No. 26, will
soon be available to anesthesiologists through their Glaxo-Wellcome
representative. This videotape was produced to help raise awareness
that the potential for drug errors is particularly high in the
operating room where a large number of potent drugs are administered
in a short period of time. Drug errors in anesthesia can involve
administration of the wrong drug, administration of the right
drug in an improper dose or by an incorrect route, or failure
to deliver the intended drug. An opening scenario in which epinephrine
is almost delivered inadvertently instead of the intended drug,
lidocaine, underscores the importance of reading the label.
During this program, the role of human error as well as that
of underlying system faults which predispose to error are discussed.
Potential system faults that are examined include product packaging
and labeling, equipment design, work environment and policies.
Consideration is given to the nature of common anesthesia-related
drug errors, some of the underlying causes and strategies for
prevention.
National, institutional and personal policy approaches to the
prevention of drug errors are described. Practical suggestions
are made for an avoidance of critical drug errors.
This videotape was shot on location at the Bowman-Gray School
of Medicine in Winston-Salem, North Carolina. Consultants for
the presentation include: Robert C. Morell, M.D., and Richard
C. Prielipp, M.D., of Bowman-Gray School of Medicine; David E.
Lees, M.D., of Georgetown University, Washington, D.C.; and Beverly
A. Orser, M.D., of Sunnybrook Health Science Center and the University
of Toronto, Toronto, Ontario, Canada.
The production of "Drug Errors in Anesthesia" was funded
in part by Glaxo Wellcome Inc. and will be distributed by its
representatives during the spring of 1997. The videotape was produced
by GWF Associates, Holmdel, New Jersey. Other videotapes in the
ASA Patient Safety Videotape Series, many of which are still available,
are listed in the accompanying box.
ASA Patient Safety Videotapes:
Cassette A
Videotape:
No. 1 - ASA Series Overview
No. 2 - Preventing Disconnection in the Breathing Circuit
No. 3 - Anesthesia Machine Checkout
Cassette B
Videotape:
No. 4 - Anesthesia Record Keeping
No. 5 - Human Error in Anesthesia
No. 6 - Adverse Events
Cassette C
Videotape:
No. 7 - Monitoring With the Six Senses
No. 8 - Monitoring With Instruments
No. 9 - Anesthesia Equipment Service: An Organized and Cooperative
Approach to Maintenance and Repair
Cassettes
No. 10 - Margin of Safety: Monitoring the Neuromuscular Junction
No. 11 - Emergence: Patient Safety in the Post-Anesthesia Care
Unit
No. 12 - The Impaired Practitioner
No. 13 - Safety Considerations in Obstetrical Anesthesia
No. 14 - Anatomy of an Anesthesia Machine
No. 15 - The Difficult Airway, Part One: The Algorithm
No. 16 - The Difficult Airway, Part Two:
Management - The Cricothyroid Membrane
No. 17 - Central Venous Catheter Complications
No. 18 - Infection Control in the Practice of Anesthesia
No. 19 - The Difficult Airway, Part Three: Fiberoptic Intubation
No. 20 - Fire in the Operating Room
No. 21 - An Anesthetic Catastrophe
No. 22 - Crisis Management in Anesthesia
No. 23 - Memory and Awareness in Anesthesia
No. 24 - Perioperative Peripheral Nerve Injury
No. 25 - Sedation and Analgesia by Non-Anesthesiologists
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