An Analysis of The Drug Error Problem in the Thai Anesthesia Incidents Study (THAI Study)
Thanoo Hintong MD,* Waraporn Chau-In MD,** Somboon Thienthong MD**, Siwaporn Nakcharoenwaree MD***
Affiliation : * Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand **Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand ***Department of Anesthesiology, Pichit Hospital, Pichit, Thailand
Objectives : To analyze the problem of drug error related to anesthesia in Thailand including nature, contrib-
uting factors and preventive strategies.
Materials and Methods : We prospectively recorded anesthesia-related drug error incidents for 18 months in 20
studied hospitals in Thailand. Types of errors and their outcomes were recorded. All data were analyzed to
identify contributing factors and preventive strategies.
Results : Forty-one drug error incidents were reported in 40 out of 202,699 anesthetized cases or 1: 4,943 in
this study. The most common type of error was wrong drug (20 incidents; 48.8%). No relationship between
anesthetic techniques and the incidents except for a combined general and epidural technique. The errors
were most commonly occurred during induction of anesthesia(26 out of 41; 63.4%) and muscle relaxants were
most commonly involved(13 out of 41; 31.7%). The majority of incidents (26 out of 41; 63.4%) caused no
adverse effect. However 14 incidents (34.1%) caused transient mild to severe physiological effects, of which
13 had complete recovery but one died. Haste and lack of recheck were two common contributing factors
which were minimized by high awareness and double check prior to drug administration. Main strategies
suggested to prevent the incidents included specific guideline development whereas the incidents did not
effectively decrease by increasing of manpower.
Conclusion : The incidence of drug error in our study was 1 : 4,943. It can cause morbidity and mortality
during anesthesia. Practitioners should be aware of these potential incidents and strictly follow the guideline
for drug administration.
Keywords : Anesthesia , Drug error, Ampoule, Syringe, Incidence, Multi-center study
