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Prevent Medication Mix-Ups in Your OR

Publish Date: May 12, 2021

Container mix-ups and syringe swaps happen all the time during surgery with similar looking vials of medication being in close proximity to the sterile field.

What if the anesthesiologist picks up a vial of tranexamic acid that the surgeon plans to use to minimize blood loss and administers it to the patient thinking its bupivacaine for pain? It’s happened, and patients have died because of this preventable medication error.

Periop teams have the power to prevent such errors with strategies such as clearer labeling and read-back of medication names prior to administration. That’s why AORN’s board of directors endorsed the new perioperative medication safety self-assessment tool from the Institute for Safe Medication Practices (ISMP) that can help teams implement safer medication practices.

This self-assessment is specific to perioperative care and is the latest in a series of medication safety self assessments developed by ISMP, with funding support provided by the FDA.

It’s designed to be used by interdisciplinary perioperative teams working in hospitals, ambulatory surgery centers, or other surgical sites to evaluate risks for perioperative medication errors and create specific safety-focused initiatives to improve medication safety.

What the Assessment Tool Covers

The self-assessment was designed by a team of perioperative and medication safety specialists, including recently retired AORN Senior Perioperative Practice Specialist Byron Burlingame, MS, BSN, RN, CNOR.

“This tool applies to every phase of perioperative care, providing a true periop picture of medication safety in your practice setting,” Burlingame shares.

Anonymous data shared by an individual healthcare facility can be compared to similar settings so periop teams can benchmark their medication safety against colleagues in further efforts to identify areas for improvement.

The self assessment also addresses compliance with risk assessments and performance improvement requirements from state and federal agencies, such as The Joint Commission and the Centers for Medicare & Medicaid Services. As with other ISMP self assessments previously created for other healthcare areas, all information submitted to ISMP is stored in a secure database and is maintained solely by ISMP.

Using the New Assessment Tool

The new ISMP self assessment is a comprehensive tool that can provide information to address many different areas where medication errors can occur in perioperative care, Burlingame says. For example, common medication errors occur when putting medications on the sterile field. “Are you following the process of double checking for readback, labeling containers? —this is the type of question the self assessment walks you through.”

Burlingame shared four tips for applying this new assessment tool in your perioperative setting:

  1. Assess as a Team
    “While an assessment may be initiated by a perioperative leader, the assessment will be most effective when conducted by a team that includes professionals who handle each phase of perioperative care,” Burlingame stresses. This team should include surgeons, anesthesia personnel, frontline perioperative nurses, as well as specialists in medication-related fields such as pharmacy, risk management, and information technology.
  2. Take Time to Prep
    Review as a team important aspects of medication management including terminology, actual practices (not what policies outline), and review the workbook and a list of FAQs in the tool, Burlingame advises. Be sure to also establish roles for completing the self assessment, such as who will record answers.
  3. Establish a Safe Environment to Share Feedback
    The self assessment is designed to collect real time information on current practices that can be shared within a just culture. “The value of this self assessment is in collecting honest information to identify all areas for improvement, and that means any team member must be able to discuss medication safety scenarios without fear of blame or retribution,” Burlingame stresses.
  4. Share Results Broadly
    After information from the self assessment is submitted to ISMP and results come back to the team, the findings provide value to a number of personnel, including the frontline, as well as educators, risk managers, and leaders in other units, as relevant, Burlingame explains. “A director will be able to look at the findings to understand how the perioperative unit is doing with medication management overall and compared to national benchmarks, while specific aspects from the results can be used to help educator teams create resources to dial in safer practices.”

    He also says the results can be shared with facility leaders to provide rationale for expenses that can be used to improve medication safety, such as building a dedicated room for compounding medications.

    “Ultimately, this self assessment can jumpstart important conversations between leaders, providers and the frontline to take a data-based approach to target safer medication practices across the periop setting.”

To obtain the new assessment tool, which will be launched on May 18, 2021, visit

Also join a FREE ISMP webinar on May 25, “ISMP Medication Safety Self Assessment® for Perioperative Settings: How to Obtain the Most Valuable, Accurate, and Useful Results.” Find details and registration information.

Read more about Key Medication Errors in the Surgical Environment from ISMP.

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