We aimed to establish the frequency and nature of drug administration error in anaesthesia (a significant subset of error in medicine) at two hospitals. Anaesthetists were asked to return a study form anonymously for every anaesthetic, indicating whether or not a drug administration error or pre-error (defined as any incident with potential to become an error) had occurred. Further details were sought if the response was affirmative. From 10806 anaesthetics, 7794 study forms were returned, representing response rates of 80% from Hospital A and 57% from Hospital B (72% overall). The frequency (95% confidence intervals) of drug administration error, of any type, per anaesthetic was 0.0075 (0.006 to 0.009), of IV bolus errors was 0.005 (0.0035 to 0.006) and of pre-errors was 0.004 (0.003 to 0.005), with no significant difference between hospitals. Overall, one drug administration error was reported for every 133 anaesthetics. The two largest individual categories of error involved incorrect doses (20%) and substitutions (20%) with IV boluses of drug. Of the IV bolus substitutions, 69% occurred between different pharmacological classes. One patient was aware while under muscle relaxation, and two required prolonged ventilation. In addition, 47 transient physiological effects were reported, of which five required intervention. We conclude that drug administration error during anaesthesia is considerably more frequent than previously reported.

Read the full review for this F1000Prime recommended article: Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

Healthcare today is the prerogative of teams rather than of individuals. In acute care domains such as anaesthesia, intensive care, and emergency medicine, the work is complex and fast-paced, and the team members are diverse and interdependent. Three decades of research into the behaviours of high-performing teams provides us with clear guidance on team training, demonstrating positive effects on patient safety and staff wellbeing. Here we consider team performance through the lens of situation awareness. Maintaining situation awareness is an absolute requirement for safe and effective patient management. Situation awareness is a dynamic process of perceiving cues in the environment, understanding what they mean, and predicting how the situation may evolve. In the context of acute clinical care, situation awareness can be improved if the whole team actively contributes to monitoring the environment, processing information, and planning next steps. In this narrative review, we explore the concept of situation awareness at the level of the team, the conditions required to maintain team situation awareness, and the relationship between team situation awareness, shared mental models, and team performance. Our ultimate goal is to help clinicians create the conditions required for high-functioning teams, and ultimately improve the safety of clinical care.