What is the term for an error caused by an anaesthetist (anesthesiologist) placing two different medications with the same shape and colour on a drug preparation shelf?

From the Guidelines

The answer is B. Latent error. This situation represents a latent error because it involves a system-level flaw that creates conditions where mistakes are more likely to occur. When an anesthetist places two different medications with identical appearance (same shape and color) on a drug preparation shelf, they create a hazardous situation that may not cause immediate harm but sets the stage for a potential medication error.

Key Points to Consider

• Latent errors are often described as "accidents waiting to happen" because they represent underlying system weaknesses.
• In this case, the failure to distinguish between medications through proper labeling, storage, or visual differentiation creates a dangerous condition where the wrong medication could easily be selected.
• This differs from a medication error (which would be the actual administration of the wrong drug) or an anesthesia error (which is too broad and doesn't specifically identify the system-level problem).

Recommendations for Prevention

• Healthcare facilities should implement safety protocols like color-coding, separate storage areas for similar-looking medications, and double-checking procedures to prevent such latent errors, as suggested by 1 and 1.
• The use of international color coding of labels for syringes, administration routes, preparation bags, patient-controlled analgesia and patient-controlled epidural analgesia devices, medication carts, and medication storage devices can also help prevent medication errors, as recommended by 1.
• Limiting the list of medications delivered and avoiding similarities in shape, color, and name, as well as establishing protocols for preparing and administering medications, can also reduce the risk of latent errors, as noted by 1.

From the Research

Medication Error Classification

• The scenario described, where an anaesthetist puts two different medications of the same shape and colour on a drug preparation shelf, leading to a potential error, is an example of a:
  • Medication error 2, 3, 4, 5, 6

Error Types

• Medication errors can occur due to various factors, including:
  • Similarity in medication appearance (shape and colour)
  • Inadequate labelling or packaging
  • Human error (e.g., distraction, fatigue)

Latent Errors

• Latent errors refer to underlying system flaws or design issues that can contribute to errors, such as:
  • Inadequate medication storage or handling procedures
  • Insufficient training or education for healthcare professionals
  • Poor communication or teamwork

Anaesthesia Errors

• Anaesthesia errors are a specific type of medication error that can occur during the administration of anaesthetics, such as:
  • Incorrect dosage or administration route
  • Inadequate monitoring or patient assessment
  • Failure to follow established protocols or guidelines