Key Takeaways: What You Need to Know to Prevent Near Misses, Medication Errors & Hazardous Exposures


Important Updates to the AORN Guideline for Medication Safety

Periop nurses and teams will find significant revisions in nearly every section of the AORN Guideline for Medication Safety.

Key changes in the Medication Safety guideline include creation of new sections on organizational oversight and technology, and revision of recommendations related to compounding, labeling, and hazardous medications. Below is a round-up of what’s new and updated in the guideline.

Organizational Oversight

Key Takeaway

Perioperative medication management and oversight is a complex process that involves interdisciplinary team members.

Update Explanation

NEW: A review of routine use of antibiotics in perioperative patient care by the facility’s antimicrobial stewardship committee can promote judicious and evidence-based use of these medications. 1.7


Key Takeaway

Medication compounding should only be performed in the OR when there is no alternative procurement method.

Update Explanation

NEW: Procurement of compounded medications from a manufacturer or from a US Food and Drug Administration (FDA)-registered outsourcing facility increases the likelihood that regulatory requirements and current good manufacturing practices are met. 3.2

UPDATED: When a compounded medication cannot be sourced from a manufacturer or outsourcing facility, the medication should be procured from a compounding pharmacy that meets USP 797 standards. 3.2.1

NEW: When they cannot be obtained from a manufacturer, an FDA-registered outsourcing facility, or a compounding pharmacy, compounded irrigation solutions should be prepared by facility pharmacy personnel to reduce the risk of contamination or errors. 10.3

NEW: Heparinized saline solution may be standardized by the type of solution used and concentration of heparin added. Process standardization may decrease the risk of medication errors and increase the possibility that pharmacy personnel can prepare these solutions. 10.4


Key Takeaway

Moving medications from the original container to a new container can increase the risk of medication errors and contamination during handling, transfer to the sterile field, and labeling processes.

Updated Explanation

Implement methods to help prevent contamination, including:

  • UPDATED: disinfecting medication vial stoppers, including at the initial entry after removal of the cap or cover with alcohol and allowing them to dry. 7
  • UPDATED: using a new sterile access device (e.g., vial spike, filter straw, plastic catheter) each time when withdrawing medication from a vial (a needleless method or blunt needle is preferred), and 8, 8.1.2
  • NEW: using a needle and syringe if the container requires it for access or if a needleless method is not available. 8.1

UPDATED: To reduce the risk for error, medications, solutions, liquids, or compounds removed from the original container should be labeled with the full name, concentration, dilution and diluent if used; no abbreviations (or only approved abbreviations); and no unnecessary information. 9.1

UPDATED: The expiration date or beyond-use date should be included on the label if the medication will expire during the procedure. This clarifies when it should no longer be used. 9.1.1

NEW: Use of preprinted, sterile medication labels on the sterile field can decrease the risk of an error related to illegible handwriting and increase standardization and compliance with health care organization policies and procedures for medication labeling and efficiency. 9.3

Hazardous Medications

Key Takeaway

Correct selection and use of personal protective equipment (PPE) when handling and administering hazardous medications is crucial.

Updated Explanation

UPDATED: Providing self-identified personnel who are actively trying to conceive, are pregnant, or are breastfeeding with an alternate duty assignment or reassignment that does not involve handling of hazardous medication can prevent hazardous drug exposures during the early stages of fetal development. 12.5

UPDATED: To prevent health care worker exposures, handling of hazardous medication should be based on regulatory requirements, manufacturer’s instructions for use, drug package insert information, safety data sheet information, and professional organization guidance. 12.6

UPDATED: Personnel exposed to vapors or cleaning large spills (i.e., IV bag breaking, disconnected tubing) of hazardous medications should wear a full-face piece, chemical cartridge-type respirator or powered air-purifying respirator (PAPR). 12.7.4

UPDATED: When there is not a risk of aerosols, either respiratory protection or a surgical mask should be selected based on the hazardous medication safety plan, procedure to be performed, medication administration processes (i.e., injection, open-air circulation in an abdomen), and the perceived risk for exposure as determined by the affected caregiver. 12.7.3

UPDATED: Goggles and single-use face shields, a disposable gown of the highest liquid barrier performance class, and two pairs of chemotherapy gloves should be worn. 12.7.5 – 12.7.11

NEW: Prevent or mitigate environmental contamination of hazardous medications by protecting the OR bed, careful placement of hazardous medication containers (i.e., on shelves, counters). 12.10 – 12.11.1, 12.13 – 12.13.3

NEW: Hyperthermic intrathoracic chemotherapy (HIPEC), hyperthermic intrathoracic chemotherapy (HITOC), and pressurized intraperitoneal aerosol chemotherapy (PIPAC) procedures should have additional interventions to protect personnel and prevent or mitigate environmental contamination of hazardous medications. 12.17 – 12.17.10

NEW: A standardized process, established by an interdisciplinary team, should be implemented for environmental surface sampling of areas where hazardous medications are administered to identify environmental contamination from hazardous medications. 12.19 – 12.19.7


Key Takeaway

Technology, documentation, and quality processes are essential for reducing, identifying, and improving medication errors from a system-based, culture-of-safety focus.

Updated Explanation

NEW: Standardization of technological devices used in medication use processes can reduce variation in processes that could lead to errors or patient harm. 16.1

NEW: Use of automatic dispensing cabinets, bar code scanning, and smart infusion pump technology can help reduce errors when used correctly. 16.2 – 16.4

UPDATED: Education, competency verification, and direct observance of personnel using the devices in the perioperative setting helps to determine how the devices are being used (i.e., according to the manufacturer’s IFU and the facility’s policy and procedure) and if there are barriers or the use of workarounds or overrides. 16.5 – 16.8

UPDATED: Documentation throughout medication use processes is a professional medicolegal standard, demonstrates compliance with regulatory requirements and accreditation standards, facilitates continuity of patient care through clear communication and collaboration among health care team members, and provides data for identifying trends in the quality of care provided. 17.1.1

NEW: Reviewing medication errors, adverse drug events, and near misses; analyzing them by phase of care and professional role (i.e., intraoperative, anesthesia provider, RN circulator, scrub person); and determining system-based root causes facilitates creating a transparent, interdisciplinary improvement plan. 19.4 – 19.7

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