The Medication Errors Task force, initiated by the Safe Anaesthesia Liaison Group (SALG) was set up at the beginning of 2024 as a short life working party to identify potential solutions to tackle the ongoing challenge of medication error-related harm in anaesthesia. This multidisciplinary task force included anaesthetists with patient safety expertise, clinical pharmacists specialising in procurement, and representatives from the following key stakeholder groups:
- Anaesthesia (Association of Anaesthetists and Royal College of Anaesthetists)
- Intensive care medicine (Faculty of Intensive Care Medicine)
- NHS England
Medication errors, such as wrong dose and wrong drug errors, represent a significant portion (25%)1 of preventable patient harm. While acknowledging that it is not possible to eliminate these errors entirely, this group has concluded that the widespread adoption of prefilled syringes would reduce the frequency of these errors and could improve medication safety across healthcare settings. These are already in use in many areas of healthcare and the WP recommended that SALG focus on supporting implementation of prefilled syringes as a priority.
What is a Prefilled Syringe?
A Prefilled syringe contains medication that is a ready-to-administer in a syringe that is filled and labelled prior to it entering the clinical area where it can be administered without further manipulation.
Why Prefilled Syringes?
Prefilled syringes offer a range of benefits, including:
- Reduction in Medication Errors: By eliminating the need for manual preparation, a prefilled syringe will reduce the risk of human factor-related error by ensuring that the drug is correctly labelled in the correct concentration in a syringe ready to administer.
- Time Efficiency: Prefilled syringes save valuable clinical time, reducing the preparation and mental workload for anaesthetists, which in turn allows them to focus more on patient care.
- Improved Sterility: Prefilled syringes that are compounded locally are prepared in a clean room, and manufactured prefilled syringes are further externally sterilised after filling, ensuring sterility and reducing the risk of infection compared to manually prepared syringes.
- Cognitive Load Reduction: With immediate availability, consistent labelling, and standardised concentrations, prefilled syringes help reduce cognitive load on healthcare workers, especially in high-pressure, time-critical situations.
- Cost saving: Despite the higher unit cost of prefilled syringes compared to ampoules, their benefits in terms of safety and efficiency make them a cost-effective choice in the long run. The cost savings associated with the use of prefilled syringes are largely due to decreased costs associated with medication errors, contamination of intravenous medication, reduction in drug waste, and cost of other drug products needed in conventional preparation methods.
- Sustainability: The use of ampoules, empty syringes, and stick-on labels is wasteful in terms of transportation and packaging of these items. Their contribution to the reduction in adverse events requiring further expensive and environmentally damaging treatment is also beneficial. Adoption of prefilled syringes for anaesthetic and intensive care medications could contribute to both environmental sustainability and cost efficiency in healthcare settings.