The SAFERsleep Project

Department of Anaesthesia embarks on major patient safety initiative

Human error is a significant problem in modern healthcare, harming patients and increasing costs.

In a prospective study of 10,806 anesthetics, Webster at colleagues [1] found a drug error of some kind occurred in 1 out of 133 anaesthetics.

In 2005, Abeysekra and colleagues [2] reviewed the nature of 896 anaesthetic incidents found that more than 50% involved syringe and/or drug preparation error.

In addition, several studies - including that of Galletly and colleagues [3] - have shown that conventional anesthetic records are often unreliable, contributing to anaesthetic incidents.

In 2006, Merry and colleagues [4] presented a milestone clinical study at the annual meeting of the American Society for Anesthesiology (ASA) demonstrating a statistically significant reduction in bolus to bolus drug error of 40.7%. This is the patient safety premise upon which the SAFERsleep System is developed.

The Department of Anaesthesia is collaborating with the Royal College of Anaesthetists (RCoA) and the NHS National Patient Safety Agency (NPSA) in a trial evaluating the 'double-checking' process in anaesthetic intravenous drug delivery.

For further information contact the Departmental Lead for the project.

References

  1. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesthesia and Intensive Care 2001; 29: 494-500. PUBMED
  2. Abeysekra A, Bergman IJ, Kluger MT, Short TG.
    Drug error in anesthesia practice: a review of 896 incidents from the Australian Incident Monitoring Study database. Anaesthesia 2005; 60: 220-7. PUBMED
  3. Galletly DC, Rowe WL, Henderson RS. The anaesthetic record: a confidential survey on data omission or modification. Anaesthesia and Intensive Care 1991; 19: 74-8. PUBMED
  4. Merry AF, Webster CS, Larssen L, Wells J, Fryben C. Prospective Assessment of a new anaesthetic drug administration system designed to improve safety. Anesthesiology 2006;106:A138.

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