FLYING SOLO The OR is one of the few patient care areas where a single person is often in charge of obtaining, preparing and administering medications.

Why do medication mistakes continue to occur? "Because too many surgical leaders have focused on weak interventions," says Joyce Wahr, MD, FAHA, vice chair of quality and safety in the department of anesthesiology at the University of Minnesota in Minneapolis. "You can change policies and procedures, and tell providers to try harder, but those are incredibly ineffective ways to address the underlying issues." Instead, says Dr. Wahr, focus on implementing fail-safe systems that stop mistakes as they're happening, before they reach the patient.

Mistakes? Yes, mistakes. A team of researchers observed nearly 3,675 medication administrations made during 277 surgeries. The results were eye opening: 124 of the cases involved at least 1 medication error (a mistake in ordering or administering a drug) or adverse drug event (harm or injury related to a drug, regardless of whether it was caused by an error). Of the 193 medication-related errors or adverse events they observed, nearly 80% were preventable.

One in 20 administrations — or 1 during every other operation — resulted in a medication error. One-third of the errors led to some kind of patient harm, ranging from skin rashes to changes in blood pressure or increased infection risk, and the remainder had the potential to cause harm.

The most common errors that led to patient harm involved wrong doses, omitted medications and failing to intervene when necessary, based on changes in the patient's condition. Karen Nanji, MD, MPH, an anesthesiologist at Massachusetts General Hospital in Boston, Mass., and her colleagues have implemented interventions designed to eliminate the types of errors they found. Can their practice improvements promote medication safety in your facility?

UNIQUE LOOK Custom medication labels differentiate drawn-up syringes that are placed on the sterile field.

1. Barcode-assisted syringe labeling. This technology was in place in most of Mass General's ORs during the study period, but 24% of the errors involved labeling mistakes when the technology wasn't installed or providers used workarounds to circumvent its use.

If you're using barcode-assisted labeling, place the technology at the immediate point of care and make sure it's user-friendly and performs fast enough to keep up with the pace of surgery, says Dr. Nanji. She also recommends that you trial any platform you're thinking of implementing to make sure it's compatible with the complexity of delivering medications in the OR. Also train your staff extensively on new technology before it's rolled out, and continue that support and training during the initial phases of implementation, to make sure your team is fully up to speed. Staff will grow frustrated with technology that's too slow or too complex to use and will opt for simpler low- or no-tech methods of medication administration.

Dr. Nanji says facilities without the capital to invest in barcode-scanning technology can still follow best practices for bringing medication to the sterile field and ensuring it's administered safely. For example, ensure the information noted on paper tape labels is full and complete. Labels should include the drug's name, dose and expiration date. Pre-printed, color-coded labels also help differentiate certain classes of medications, says Dr. Nanji.

2. Barcode-assisted documentation. These systems let providers scan medications immediately before administration to automatically populate the electronic medical record with the type and dose of medications given. The technology can eliminate documentation errors.

During her study, Dr. Nanji found that most providers documented medications after they were administered. Point-of-use documentation technology requires providers to scan medications before administration so such safeguards as allergy alerts and dosing calculators are fully used.

Barcode-assisted documentation systems can also prevent monitoring oversights or failing to act when the patient's condition changes. For instance, systems can remind providers to re-dose antibiotics or check the patient's blood pressure when 10 minutes have elapsed since the last reading.

3. Eliminate workarounds. Consider medication administration improvements in the OR that provide additional layers of verification and minimize opportunities for providers to circumvent safety checks and processes. For example, they'll continue to use paper labels if they're stored right next to barcode-assisted labeling technology, says Dr. Nanji.

"In general, you want to make the safety solution the easiest course of action," says Dr. Nanji. "The safeguard should not disrupt workflow and make patient care more difficult for providers. If it does, staff will continue to use the easiest possible method to administer medications, even though it might not be the safest."

4. Strengthen handoff procedures. Mistakes made during patient handoffs can lead to future medications errors. Always take a few minutes to ensure transitions of care are done properly and the needed information is shared among providers in different phases of the perioperative pathway.

Checklists are very effective in ensuring a patient's medication history, medication allergies and potential drug-drug interactions are covered, even in time-pressured environments. Also address medications that have already been administered — antibiotics, anesthetics, narcotics — so there's no chance of repeat dosing without knowledge of a previous dose. Create your own checklist based on the medication needs of your patient population and the specific types of surgeries your facility hosts.

5. Avoid common pitfalls. Dr. Wahr says it's imperative to foster a non-punitive, real-time error reporting system, so you can quickly identify breakdowns in medication administration processes that set your providers up to fail. For example, use "tall man" lettering to differentiate similarly spelled medications and store drugs with look-alike and sound-alike names in non-adjacent bins in the anesthesia tray.

6. Standardize. Standardize anesthesia drug trays in every OR, says Dr. Wahr. She suggests you develop a basic tray that's used during every case, and add ancillary trays for specific surgeries that require additional medications. Prefilled, premixed medications eliminate having concentrated medications, or drugs that need to be diluted, in the anesthesia cart and help ensure the right dose of the right medication is administered.

7. Know the route. "Some of the most catastrophic events occur when perfectly prepared medications are administered by the wrong route," says Dr. Wahr. She recalls when an epidural bupivacaine infusion intended to enter the epidural space at a low rate was mistaken for an antibiotic and administered to a pregnant woman. The baby was saved, but the mother died. Route-specific connecting systems — enteral and near neuraxial — are now available to ensure medications are administered the correct way. "The best thing to do, as quickly as possible, is to start using those unique infusion lines," says Dr. Wahr.

Prevent defense
Keep in mind that Mass General, a national leader in patient safety, had already implemented processes to improve medication delivery in the OR when the study took place. So it's safe to say medication error rates are probably at least as high at your facility.

"There's definitely room for improvement in efforts to prevent perioperative medication errors," says Dr. Nanji. "Identifying the types of errors that are being made allows for the development of targeted strategies to prevent them from happening." OSM