Abstract:
The rate of injury and death inadvertently caused by medical treatment is too high and exacts enormous human and financial costs. Each year in Britain and the United States alone, hundreds of thousands of patients are injured, ten of thousands are killed and billions of dollars are spent on additional health care due to iatrogenic harm. Health care organisations remain predominately human-centred in their approach to safety-that is, methods of avoiding error rely primarily on the resolve and vigilance of individual clinicians to avoid bad outcomes. However, this approach is becoming increasingly inadequate in the face of the steadily rising complexity of modern health care and the increasing number of procedures carried out each year. In other high-reliability organisations such as aviation and nuclear power generation, safety results not from the sheer effort of “operators”, but from in-depth analysis of problems and the removal and redesign of dangerous aspects of systems-the so-called systems approach. Here I present an evaluation of the integrated drug administration system (IDAS) as an example of the systems approach, intended to reorganise the way in which anaesthetists give drugs to improve performance and facilitate safe practice. The problem of drug error in anaesthesia is an important subset of iatrogenic harm in medicine. From the prospective study of 10806 conventional anaesthetics I define the rate of drug error in anaesthesia as one error in every 133 anaesthetics conducted-a rate five times higher than anything previously reported. In addition, anaesthetists rated the risk of harming a patient through drug error in the course of their career as high. I discuss the principles of safe system design, the psychology of error, and advanced systems safety concepts with respect to the design of the IDAS and the future of safety in medicine. In clinical use, the IDAS saved time before and during anaesthesia, and was rated by anaesthetists as significantly safer and more useable than conventional methods of drug administration. This work supports the hypothesis that error in anaesthesia can be reduced through the systematic analysis of its causes and the implementation of appropriate countermeasure strategies.
