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To clarify the incidence of anesthesia-related medication errors in Kyushu University Hospital, a retrospective analysis of anesthesia-related incidents from 1993 to 2007 was conducted based on the“In...vestigation of anesthesia-related medication incidents”by the Japanese Society of Anesthesiologists. Out of a total of 64,285 anesthesia cases, drug errors occurred in 50 cases (0.078%), but none of the incidents led to serious sequelae. Wrong medication was the most common type of drug error (48%), followed by overdose (38%), underdose (4%), omission (2%), and incorrect administration route (8%). The most commonly involved drugs were opioids, cardiac stimulants, and vasopressors. Syringe swap was the leading cause of wrong medication, accounting for 42%, drug ampoule swap occurred in 33%, and the wrong choice of drug was made in 17%. The first, second, and third most frequent causes of overdose involved a misunderstanding or preconception of the dose (53%), pump misuse (21%), and dilution error (5%). The error frequency did not decrease over the 15-year period. The responsible anesthesiologists were most likely to be doctors with a little experience. To reduce anesthesia-related medication errors, improvements of protocols for handling medication and instruction, and an improved education system for the anesthesia trainees are essential.
九州大学病院における麻酔関連薬剤投与のインシデントの実態を明らかにすることを目的に，日本麻酔科学会「麻酔関連薬剤の投与に関するインシデント調査」に基づき，1993 年から2007 年までの麻酔関連偶発症例を後ろ向きに調査した．麻酔科管理64,285 症例のうち，薬剤投与関連のインシデントは50 症例（0.078％）に認められた．全例，後遺症なく転帰良好であった．発生事象の種類の内訳は誤薬が48％，過量投与が38％，過少投与４％，投与すべき薬剤を投与しなかった症例２％，投与経路の誤り８％であった．投与薬剤の種類ではオピオイド，強心薬・昇圧薬が多かった．誤薬が発生した段階の分類では，シリンジを選別する段階での誤り42％，アンプルを選別する段階での誤り33％，勘違い17 ％であった．過量投与が発生した段階の分類では，投与量に関する誤解や思い込み53％，シリンジポンプの操作の誤り21％，希釈の誤り５％であった．15 年間の推移上，発生件数の減少傾向は認められなかった．麻酔担当医の資格別にみると，麻酔科標榜医を有さない麻酔科医が48％ともっとも多く，ローテータ（30％）が続いた．薬剤投与に関するインシデントを予防するためには，薬剤取り扱いおよび指示に関する業務手順の改善と麻酔科研修医に対する教育・オリエンテーションの徹底が求められる．show more
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