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Anestesia Analgesia Reanimación
versão impressa ISSN 0255-8122versão On-line ISSN 1688-1273
Resumo
RANDO, Karina et al. Safety in anesthesia: an error in the administration of LASA drugs. Anest Analg Reanim [online]. 2017, vol.30, n.1, pp.42-61. ISSN 0255-8122.
Patient safety is a priority in the surgical anesthetic area, and errors in drug administration area frequent cause of critical incidents in the perioperative period. One type of error is the administration of the wrong medication due to similar presentations.
The objective of this study is to describe the failure of barriers to prevent critical drug incidents; this is based on the study of a clinical case and an analysis of its consequences.
Methodology
. Description of a clinical case and systematic study of the risk situation based on the taxonomic analysis of the patient, individual, task, human team, workplace, and organization (PITELO), as suggested by the Spanish System of Safety Notification in Anesthesia and Resuscitation (SENSAR).
Results
. A healthy woman presented in respiratory arrest after the intravenous administration of a drug in the postoperative period. It took 24 hours of intensive care and multiple studies before an error in drug administration was diagnosed. The confusion was presented with a pair of LASA (look-alike, sound-alike) ampoules of atracurium and ranitidine drugs.
Photographic documentation evidences the similarity of the ampoules themselves, and the diagram identifies latent system failures. The costs of the error are estimated and proposals for improvement are provided.
Discussion and Conclusions
. There is evidence of a failure in the barriers to the prevention of adverse events and in the reporting system. It is necessary to increase the safety culture at all levels of the system: regulatory, institutional, and personal.
Palavras-chave : Medication error; LASA; Anesthesia; Safety.
