The surprising revelation that lethal amounts of propofol contributed to the death of Michael Jackson and the headline-grabbing case of surgical tech Kristen Parker, who exchanged soiled needles filled with saline solution for fentanyl syringes at 2 Denver-area facilities, have highlighted the importance of keeping medications secure. Less-publicized mistakes related to drug delivery mix-ups happen every day, putting patients at avoidable and unnecessary risk. If you haven't recently reviewed your medication safety protocols, now is the time. Follow these 6 tips to get started.

1. Focus on proper labeling.
Write out doses or dosing instructions instead of using shorthand — IM (intramuscular) can resemble IV (intravenous), for example. Proper labeling also calls for distinguishing between look-alike and sound-alike drugs. Celebrex, Cerebyx and Celexa, for instance, are easily confused at the front line. Use "tall-man lettering" when labeling look-alike and sound-alike medications, employing all caps for the parts of the names that are different (hydrALAzine and hydrOXYzine, for example, or DOPAmine and DOBUTAmine). Store drugs like these in different colored, non-adjacent bins to help avoid confusion.

Remember that labels used in the OR must be sterile. Consider purchasing customized, sterile labels to standardize medication notations and to facilitate the labeling process. Never pre-label syringes, however. The person drawing medications should apply labels as soon as syringes are filled. Labels must include the drug's name, dose strength and expiration date if it's shorter than 24 hours.

2. Confirm orders.
Avoid verbal orders whenever possible due to the complex names of some medications and the danger of administering the wrong medication when sound-alike drugs are involved. Verbal orders, however, are the norm in the OR, placing particular importance on effective communication between surgical staffers at the point of service.

Always repeat verbal orders to confirm the right dose of the right medication. When asked for propofol, for example, make it a habit to show the drug to the person making the request and to repeat the drug's name and dose, saying, "Here's your 20mg of propofol." When making a request, expect to receive verbal confirmation. Don't hesitate to question the passer if you don't hear your order repeated back. Verbal communication lets at least 2 sets of ears and eyes confirm the passing of correct medications. It also provides everyone in the OR an opportunity to observe the exchange, increasing the number of people who can confirm the correct medication and speak up if the wrong drugs are passed.

All clinical team members have biases or certain expectations that can sometimes lead to medication errors. Your facility, for instance, likely hosts cases that require similar medications to control pain or prevent PONV. The routine of surgery lets caregivers anticipate the medication needs of certain patients, letting them work a step ahead of the anesthesia provider or surgeon.

That's a good thing, especially in the fast-paced world of surgery. But what if the anticipated medication isn't needed? Repeating the same medication identification process, even during routine cases, establishes a communication standard for every exchange that becomes truly valuable when a drug request goes against the norm.

Make sure your record of the medications patients are taking is accurate and complete and remains accurate from the patient's arrival, through handoffs, dose changes and additions, to the patient's discharge. Without verification, a small mistake or omission can become a big error in patient care. Provide patients with a list of their medications at the time of discharge, send it to the next provider they'll see and continue to keep it at your facility for future reference.

3. Increase security.
Secured drugs are likely highly supervised if you work in a large facility. Those of you in smaller surgery centers, however, might need to focus on securing addictive medications and tracking their use. Require that personnel record each time they access secured drugs. They should note the drugs they pull for cases, the dose amounts and the date of access. Also require 2 signatures to document the proper disposal of medication waste — 1 from the person disposing of the waste and another from the person supervising the disposal.

Keeping medications secure has become a topic of interest at all levels of health care, thanks in part to Ms. Parker's drug-diverting exploits. Employees who abuse drugs may not perform their jobs with the appropriate mental discipline or, worse, might infect patients with an incurable disease. To date, at least 27 patients have contracted hepatitis C thanks to dirty needles left behind by Ms. Parker.

Michael Jackson's death highlighted issues surrounding the security of propofol, which the Drug Enforcement Administration does not consider a controlled substance due to what the agency believes is a low abuse potential. But that belief might be shifting in the healthcare sector. In June the American Association of Nurse Anesthetists issued a position statement regarding propofol security. It states, "The ease of access to propofol may contribute to the incidence of abuse, addiction, and death among anesthesia providers and other healthcare professionals." The AANA recommends that facilities maintain propofol in a secured environment to reduce the likelihood of diversion and limit its availability to approved personnel only.

4. Track usage.
Automated storage systems dispense drugs to anesthesia providers as needed, limiting access to amounts specified for individual cases. In addition, the systems keep electronic records of who accessed secured drugs, when they did and the amount they took. The automated systems supply data that can help you identify drug diverters.

For example, computerized charting provides automatically generated audit tools that track provider activity on a monthly basis. You're able to identify drug-dispensing anomalies by comparing the medications anesthesia providers request against the medications they chart. Does the amount of drugs wasted after cases make sense based on the amount of drugs requested? How does medication use compare across anesthesia providers in your facility?

With a few clicks of the mouse you can generate reports that compare drug usage between providers or flag deviations from typical drug dispensing amounts. The storage systems aren't cheap — some run as much as $20,000 — but in my opinion the peace of mind is well worth the additional cost.

5. Stay vigilant.
Automated storage units limit access to controlled substances, but no safeguard is more effective than diligent oversight of medications by anesthesia providers. Providers should ensure medications remain in their presence whenever the drugs aren't in secured storage. Leaving vials unattended on the sterile field, even for a few seconds, is a recipe for trouble.

Be on the look out for any imperfections to drug storage containers or delivery devices, no matter how minor they seem. Investigate all complaints from patients who feel as if they didn't receive sufficient pain control during a case and report any evidence of drug tampering to the DEA.

Be aware that drug abusers get very creative when trying to feed their addictions. The DEA documented a case of a healthcare worker who used a lighter to heat the tip of a 16-gauge needle before poking it through the bottom of a fentanyl vial. The worker discovered that the needle's heated tip melted the vial's glass and resealed it as it was pulled out. Only a small white dot on the bottom of the vial remained as evidence.

6. Simplify delivery protocols.
In August an Ohio pharmacist was sentenced to 6 months in jail and 6 months of house arrest after he approved a lethal dose of sodium chloride that killed a 2-year old patient during a routine chemotherapy treatment. The tragedy occurred, in part, because a pharmacist tech made a calculation error while unnecessarily adjusting the tonicity of the sodium chloride to the ideal 0.9% mixture, even though administering twice the normal amount wouldn't have affected the solution's efficacy. It was a mistake that didn't need to happen, leaving us with a simple take-home message: Take a critical look at your medication delivery protocols. Is each step adding value to the process? If not, what steps can be eliminated? The most basic guidelines are often the easiest to follow and the most effective in practice.