Safety, cost and predrawn emergency drugs.

We were interested to read the recent discussion concerning the predrawing of ‘emergency’ drugs in the obstetric theatre (Cupitt & Dunkley. Anaesthesia 2000; 55: 721. Calow. Anaesthesia 2000; 55: 1226–7) and the call for the experiences of others. We have recently published a national survey of the attitudes and practices of New Zealand anaesthetists with regard to emergency drugs [1]. The results demonstrate no uniformity of opinion or practice in New Zealand and indicate that many factors influence which drugs, if any, are predrawn before a case. Eighty-four per cent of respondents reported that their institution had no policy regarding the predrawing of emergency drugs in their workplace. The most common drugs to be predrawn were succinylcholine, atropine, syntocinon, ephedrine and metaraminol. Twenty-six per cent of respondents reported routinely predrawing such drugs, the majority indicating that they did this to avoid delay and to be prepared – some adding that assistants were too slow in drawing-up during emergencies. Thirty-seven per cent of anaesthetists reported having experienced delay, and 30% errors, while drawing up a drug at the time of a crisis. A number of respondents indicated that the absence of predrawn emergency drugs increased the anaesthetist's stress level even if the patient's outcome was not affected by delay in administering a required drug. Contrary to the widely held view that emergency drugs are rarely used, 86% of respondents had used such drugs in the previous year, and 29% had required them more than five times [1]. There is a significant cost in preparing and discarding syringes on a daily basis. Extending their shelf life is certainly the simplest way to decrease this cost, and it may be relatively straightforward to achieve a shelf life of a week or more. A recent US study investigated microbial contamination in over 700 syringes of six common emergency drugs drawn up in an obstetric theatre under routine clinical conditions [2]. The syringes were covered with clean towels and stored in theatre, unrefrigerated, next to the anaesthetic machine; no microbial contamination was found in any syringe after 8 days. However, consideration is also needed of drug stability, and of the possibility of chemical or particulate contamination from the syringe materials. Adequate quality control probably does require the formal procedures of a hospital pharmacy or licensed pharmaceutical manufacturer, which in many cases would permit shelf lives of several months to be attained – more than offsetting any additional costs. Given proper quality control, the advantages of presenting drugs in a prefilled format are several, and go well beyond the emergency situation. The use of such syringes may well be one method of reducing the very worrying problem of drug administration error [3]. It is well known that the legibility of labels on many ampoules is poor, and that ampoules containing quite different drugs may closely resemble each other, creating what psychologist and systems expert, James Reason, has called a latent error [4, 5] (Fig. 9). In this way, one of the authors recently committed a drug administration error by mistakenly substituting the two left-most ampoules in Fig. 9. Pre-filled syringes replace the error-prone, complex task by which an anaesthetist places several different drugs into individual syringes, with the much safer, production-line process by which a manufacturer prepares a large number of syringes containing the same drug [6]. The standard of user-applied labelling of drugs drawn up in theatre is typically variable and idiosyncratic, often little better than the labelling on ampoules and, at times, frankly dangerous [7]. Standard production methods would virtually guarantee the accuracy of labelling and would facilitate the use of highly legible, printed labels, incorporating the drug-class specific, international colour-codes for anaesthetic drugs. We have adopted such prefilled syringes at Green Lane Hospital (for some 10 drugs) as part of a systematic approach to the reduction of drug administration error (Fig. 10) [3]. In the case of emergency drugs, prefilled syringes could be presented in easily recognizable tamper-evident packs. The contents of these packs could be determined by departmental policy and could be speciality specific. Packs could be available from a different drawer of the anaesthetic trolley, thus physically separated from drugs commonly used during uneventful anaesthesia. Such physical separation and effective labelling would surely assist in reducing the incidence of syringe-swap errors. There would be some extra cost, at least initially, in the adoption of this approach. However, there is a substantial cost associated with iatrogenic harm, and recent calls for greater patient safety by the US Institute of Medicine [8] reflect a growing public intolerance of error in healthcare. At the least, the additional expenditure involved with providing emergency drugs in prefilled syringes would be minimal and, as Calow suggests, would be very likely to reduce risk to the patient. In addition, our data suggest the provision of prefilled emergency drugs would also reduce stress for the anaesthetist [1]. The cost involved would be greatly reduced by economies of scale. Therefore, we believe the time is long overdue for pharmaceutical companies to move towards abandoning poorly labelled and time-wasting ampoules as obsolete, and to provide all injectable drugs in prefilled syringes clearly labelled according to internationally agreed standards.

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