Human factors and medication safety

I commend Kelly et al. [1] on their well-written guidelines for implementing human factors in anaesthesia, though I read it with a mixture of admiration and despair. It is profoundly disappointing that the use of prefilled syringes has found no place in the list of recommendations and that, instead, the avoidable practice of picking ampoules from boxes and manually drawing up medication is officially endorsed. It is as though the principles of human factors, so clearly and rigorously applied in the rest of the guidance, have been suspended when it comes to medication safety. Drawing up medication in the acute clinical environment is associated with a 17-fold increase in errors [2]; unacceptable rates of bacterial contamination [3]; and significant levels of harmful cognitive load. Anaesthetists are drawing up drugs at such a rate that adherence to even the most lenient intravenous medicines preparation policy is impossible. The only way to “incorporate human factors principles” into this process is to remove it altogether. The guidance disappointingly ignores this. Instead, there are appeals to improve ampoule labelling aimed at a generic drug industry which can barely supply our basic needs, and sub-recommendations, buried deep in the text, that prefilled syringes should be used “where available”. The availability is the problem, and until bolder recommendations emerge from our professional bodies, so it will remain. Our collective timidity is also partly responsible for the debacle of the Carter Report [4], which is an innovative and workable parliamentary proposal to supply prefilled syringes almost everywhere except in anaesthesia settings. That our profession could be entirely ignored by such an important initiative is nothing short of humiliation. The road to universal provision of prefilled syringes will not be quick or easy, but it starts with statements of intent and setting of standards. It requires us to highlight, quite apart from anything else, that manually preparing intravenous medication is indefensible in terms of human factors. The institutional indifference to prefilled syringes is costing lives; these otherwise excellent guidelines have missed a big opportunity to take a step in the right direction.