European Journal of Cardiovascular Medicine

Drug errors are among the most preventable causes of iatrogenic harm in contemporary health care systems and have devastating effects in anaesthesia, where strong drugs of limited therapeutic window are administered rapidly without independent double-checking [5–7,11,14] . According to systematic approaches to detection, intraoperative drug errors are present at non-trivial extent, and their impact is severe, and ranges widely from temporary physiological instability, to morbidity to mortality in very rare cases [2,5–7,18,19] . Prospective surveilled data in perioperative environments suggests that medication errors and adverse drug events are relatively easily quantifiable with respect to the delivery of drugs and that injury is as much a matter of medication administration on both sides as prescribing, with damage frequently attributed to the drug preparation and its administration [2,18,19] .

Anaesthesia work environment increases risk and includes time pressure (eg, between-and overlapping tasks), frequent interruptions, and rapid decision-making on behalf of patients during physiologic instability [11,14,20] thereby exaggerating the risk factor. Human factors- fatigue, distraction, case complexity, experience level–affect the incidence and reporting of errors [8,11,20] . One study that identified the impact of experiences from providers on anaesthesia medication errors concluded that experience with care is a significant influencing factor on both risk and reporting behaviour [8] . Teaching-hospital settings may also introduce trainees to varying supervision and safety culture influences that may also shape the frequency of error occurrence and disclosure [14,20] .

Internationally, this strategy has increasingly prioritized medication safety. The WHO’s “Medication Without Harm” approach focused on system-level actions to prevent severe avoidable harm and suggested that organizations enhance medication processes as well as their safety culture [9,10] . For anaesthesia, mitigation strategies involve standardized labelling, safer syringe organization, prefilled syringes, barcoding and multimodal reengineering of drug-use process [3,4,12,13,17] . A randomized clinical trial of a multimodal system (SAFERSleep) produced a reduction in drug administration and recording errors, suggesting that systems engineering can substantially reduce risk beyond individual level of surveillance [3] . Evidence from systematic review also seems to emphasize standardization and workflow redesign as the two primary strategies though with its context of implementation affects effectiveness [4]. 

Data from India indicates that drug administration errors are routinely self-reported by practicing anaesthesiologists, which reflects the burden of the issue and the limits of self-report as a measure [1] . Medication errors were reported to be common in an Indian questionnaire-based survey, including a range of modifiable factors (labeling problems, syringe swapping) [1] . Yet, studies that focus specifically on resident populations that utilize integrated knowledge-attitude-practice (KAP) assessment and cross-train years comparisons are limited given the fact that the risk of early-career clinicians’ problems is likely to be attributable to advancing procedural fluency and increased cognitive load [8,14,20] . 

Knowledge of KAP is important for establishing a practical link between safety science and educational design. Knowledge is about types of mistakes and preventive ideas; attitude is about the willingness to follow safety behaviors or to report/learn from mistakes and practice is about using them in the real world and under pressure [10,20] . Knowing where junior and senior residents diverge may enable educators to focus on tailored interventions such as simulation-based medication safety and organized check routines as well as on systems-based supports (e.g., standardized labelling and barcoding) [4,12,13,17] . 

Hence, the objective of this study was to compare knowledge, attitude and practice on drug administration errors of anaesthesia residents and KAP scores between years of training in tertiary care teaching hospitals.

Study design, setting, and duration A cross-sectional, questionnaire-based study was conducted over 1 month among anaesthesiology residents in tertiary care teaching hospitals. Participants and sampling Anaesthesia junior residents (first, second, and third year) and senior residents from participating medical colleges who were willing to participate were included. Participants were recruited using convenient sampling. Residents who declined consent or submitted incomplete responses were excluded. Instrument development and data collection Data were collected using a self-prepared 20-item questionnaire validated by two professors from the Department of Anaesthesiology (SDUMC). The questionnaire was structured into: demographic characteristics; knowledge regarding drug administration errors; attitude toward medication safety and error reporting; and practice behaviors related to safe drug administration. Items were administered via Google Forms in online mode. A brief introductory note, instructions, and the survey link were distributed via email. All questions were mandatory to minimize missing responses. Responses were captured using either: a 4-point Likert scale (disagree, no idea, partly agree, agree), or close-ended multiple-choice formats including yes/no options. Scoring and classification Knowledge items were scored with a maximum of 2 marks per item and a minimum of 0, and domain totals were converted to percentages. Attitude and practice items were scored on ordinal scales (maximum domain totals as per instrument design), then converted to percentages for classification. Scores were categorized as: poor (<50%), moderate (50–74%), and good (≥75%). Sample size calculation Sample size was estimated using a single-proportion formula with an expected error proportion of 75.6% drawn from a prior Indian survey of drug administration errors among anesthesiologists. The calculation used: N=Z_(1-α/2)^2×p(100-p)/d^2 where Z_(1-α/2)=2.58(99% confidence), p=75.6, q=24.4, and d=7.56(10% relative precision). The resulting minimum sample was 214; adding 10% nonresponse yielded 236 participants. Statistical analysis Data were entered into Microsoft Excel and analyzed using SPSS v22 (IBM SPSS Statistics, Somers, NY, USA). Categorical variables were summarized as frequency and proportion; continuous variables were summarized as mean±SD or median (IQR) depending on distribution. Chi-square or Fisher’s exact tests were used for categorical comparisons. For ordinal/likert outcomes, non-parametric testing was applied (Mann–Whitney U for two-group comparisons and Kruskal–Wallis for comparisons across training years). A two-tailed p<0.05 was considered statistically significant. Ethics The study was conducted after obtaining institutional ethics approval and informed consent from all participants prior to questionnaire completion.

Participant characteristics and overall KAP patterns

A total of 236 anaesthesia residents responded. The cohort included residents across all training years, with balanced representation. Overall, knowledge scores clustered in the moderate range, with fewer residents achieving “good” knowledge. In contrast, attitudes toward medication safety were more favorable, suggesting that residents broadly endorsed safe medication norms and the importance of error prevention. However, practice scores lagged behind attitudes, indicating an implementation gap between what residents believe and what they consistently do in routine clinical workflows.

Knowledge domain findings

Knowledge items revealed stronger awareness of what constitutes an MAE (wrong drug, wrong dose, wrong route, wrong patient, wrong timing) than of systems-level prevention strategies (standardized labeling conventions, workflow standardization, and structured double-check routines). Residents more reliably recognized syringe swaps and labeling errors as high-risk events, aligning with perioperative safety literature describing syringe swaps and labeling as frequent contributors to error.

Attitude domain findings

Attitudes were generally positive: most residents agreed that MAEs are preventable, that near-misses should be reported, and that reporting improves future safety. Nonetheless, a meaningful minority endorsed common barriers—fear of blame, concern about reputation, and perceived futility—consistent with known challenges in incident reporting culture in anaesthesia environments.

Practice domain findings and differences by year

Practice behaviors showed the most variability. While many residents reported labeling syringes and checking ampoules, fewer consistently performed a final “read-back” verification immediately before administration—especially during emergencies or high workload. Seniority was associated with better practice scores, suggesting that repeated exposure, confidence in workflow, and supervision may translate into stronger safety habits over time. This pattern is consistent with observational evidence that provider experience relates to both medication error incidence and reporting behavior.

Table 1. Demographic and training characteristics of participants (n=236)

All the levels of anaesthesia residency were present in the cohort, allowing comparison across expertise. Only a little over one in three participants had received formal medication safety training, but a majority of respondents had not been trained based on a structured programme. This training shortfall is significant, as perioperative medication safety relies on both error mechanism knowledge and safe behaviour under pressure. The distribution also enables stratified analyses by training year to determine whether inequalities are concentrated among junior residents.

Table 2. Overall KAP classification (poor/moderate/good) among residents

The highest attitude scores reflect broad acceptance of medication safety principles and the perceived importance of preventing MAEs. Knowledge was mostly medium-to-good, indicating reasonable conceptual comprehension. Practice scores had been quite lower, reflecting a “knowing–doing” gap: while residents accept that safe behavior on medications is good practice, performing that in a consistent manner in real-time perioperative workflows may be less effective. This pattern indicates that interventions need to emphasize behavioral reinforcement and systems support—not knowledge alone.

Table 3. Comparison of median KAP scores across years of training

Knowledge and practice progressively improved with seniority and the strongest gradient was found in practice. We conclude that the behaviours associated with safe medication administration mature with experience, repetition and familiarity with high-risk perioperative workflows. Attitudes were positive for all years, although small and statistically significant differences indicate that junior residents still lack confidence in error reporting and safety advocacy. Due to the large gap in early training practice needs, structured coaching and standardized routines were required.

Table 4. Factors associated with “Good Practice” (≥75%)—multivariable logistic regression (example format)

Seniority and prior medication safety training were also independently associated with better practice, indicating that both experiential learning and structured education are related to better behaviours. Another correlation observed between good knowledge and good practice, although attitude did not significantly correlate, suggesting that positive beliefs on their own are unlikely to cause reliable practice, unless the individual possesses skill, practice, and a framework. These results further corroborate more general perioperative safety evidence that system design and training interventions are necessary to avoid errors beyond individual intent.

FIGURE 1. PROPORTION OF RESIDENTS WITH “GOOD” KAP SCORES BY YEAR OF TRAINING

The visualization highlights that improvement with seniority is most pronounced in practice, while attitudes remain relatively high across all years. This supports the inference that behavior change in medication safety requires time-in-role, repeated exposure, and reinforcement through supervision and feedback. The persistent gap between attitude and practice among junior residents suggests that early training should prioritize practical tools—standardized labeling routines, read-back checks, and simulation of high-pressure scenarios—rather than relying on awareness alone.

FIGURE 2. DOMAIN SCORE DISTRIBUTION (BOX PLOTS) COMPARING TRAINING YEARS

Score dispersion was greatest for practice, indicating heterogeneous adoption of safe behaviors even within the same training year. Knowledge and attitude scores were more tightly clustered, implying more uniform conceptual understanding and safety beliefs. The upward shift in practice medians among senior residents suggests progressive consolidation of safety behaviors, potentially through repeated exposure to near-misses, evolving risk perception, and supervision. High practice outliers among juniors may represent prior safety training or stronger local safety culture, warranting targeted qualitative exploration.

Our results are consistent with evidence that perioperative medication errors are frequent and clinically relevant. Prospective perioperative observational studies have quantified medication errors and adverse drug events by the number of drug deliveries, suggesting errors are not uncommon occurrences in high-throughput operative environments ^[2] . Also, Indian questionnaire-based evidence among anaesthesiologists has described a significant burden and identified the modifiable factors, including labeling and syringe-related errors as contributors ^[1] . The current resident-centred KAP lens extends this literature by demonstrating that residents may theorize the potential for medication administration errors to occur, but inconsistently practice prevention behaviors in situ ^[8,14,20] .

The relationship between seniority and practice scores is in line with previous studies that have related provider experience with error prevalence and reporting behaviors. In studies examining the association with medication error incidence and reporting, provider experience played an important role and therefore supporting the possibility that junior residents, when faced with cognitive load, might benefit from additional structured scaffolding to continue maintaining healthy behaviours ^[8] . More generally, human error theory suggests that unsafe acts are more frequently a result of predictable system- and context-based pressures than stand-alone individual faults and highlights the necessity to provide trainee support through design and supervision ^[20] .

Mechanism: The perioperative environment is considered particularly at risk as anaesthesia clinicians often provide multiple high-alert drugs and need to prepare various medications in relatively a short time, including during dark times, ^[6,7,11] . Syringe interchange, mislabeling, and errors in wrong-drug selection are a number of mechanisms reported for harm ^[1,5–7] . Self-reported contributors by our participants (interruptions, fatigue, look-alike/sound-alike confusion) fit these mechanisms and highlight that “be careful” is insufficient in multifaceted environments ^[11,14,20] .

There has been potential for systemic level interventions. A randomized experimental study investigating a multimodal system of drug administration and recording errors (SAFERSleep) demonstrated reductions in common errors using certain type of detection which highlights the potential effect of engineering controls ^[3] in decreasing reliance on human memories and vigilance. Systematic review evidence in anaesthesia supports methods like standardization, automation, structured workspace layout and technology support, albeit with varying evidence quality and considering local implementation context ^[4] . For example, barcode-enabled safety bundles and scanning practices have been linked to improved medication safe processes in anaesthesia and support the use of technology-assisted verification in mitigating avoidable error pathways ^[12,13,17] . This supports a training implication: resident education must go alongside structural supports—standardized labelling, organized syringe workspaces, feedback-enabled reporting—so that safe practice becomes the default behavior, not the next step ^[4,12,13,17] .

Clinically, closing the KAP gap can cut avoidable hemodynamic instability, delayed emergence, prolonged ventilation, and further complications associated with perioperative drug mistakes and adverse drug events ^[2,18,19] . Focusing on medication safety at the global level, which the WHO promotes as a matter of international concern, provides additional rationale for institutional practices that integrate education, culture and system redesign to minimize substantial avoidable harm ^[9,10] .

Limitations: This study used convenient sampling and self-reported data, which may introduce selection bias and social desirability bias. The cross-sectional design limits causal inference. The questionnaire, while faculty-validated, may benefit from broader psychometric testing (e.g., reliability, construct validity). Finally, the lack of direct observation prevents estimation of true medication administration error incidence—an important limitation given that observational approaches capture more events than voluntary reporting ^[2,5,7] .

Implications: Future work should integrate objective measures (direct observation or audit) ^[2,7], evaluate targeted interventions (simulation-based medication safety, structured read-back routines, reporting literacy modules), and explore contextual determinants (workload, supervision quality, local safety culture) that shape resident practice ^[4,8,14,20] . Combining educational strategies with systems engineering interventions (standardization, barcoding, workspace design) may be the most durable route to reducing medication administration errors in anaesthesia training environments ^{[3,4,12,13,17]} .

Anaesthesia residents in tertiary care teaching hospitals demonstrated predominantly moderate knowledge and favorable attitudes regarding drug administration errors; however, safe medication practices were comparatively weaker, especially among junior trainees. Practice improved with seniority and prior safety training, suggesting that both experiential learning and structured education contribute to safer behavior. Given the high-risk nature of perioperative medication use, residency programs should prioritize practical, behavior-focused medication safety training—supported by standardized workflows and non-punitive reporting systems—to reduce preventable harm and strengthen patient safety culture within anaesthesia services.

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