Medication safety and clinical efficiencies go hand-in-hand. Any techniques or technologies that get the right medications to the right patient at the right time without inhibiting clinical routines will also keep your case schedule on track. While improving your medication safety practices takes more focus, it should never entail additional work. That's where these 5 tips can help.

1. Buy smaller doses. Buying medications in bulk is the cheaper alternative, but also a great threat to safe medication use. Why? Your staff must break bulk packaging down into final-dose units, a task jeopardized by the potential of human error. For example, a 50cc bottle of lidocaine is less expensive than pre-packaged doses of the drug, but what if a majority of your cases require only 2cc of the local anesthetic? Your staff would have to re-puncture the bottle up to 25 times, creating the possibility of cross-contamination, incorrect dosing and sharps injuries. And every time you puncture multi-dose vials, minute pieces of rubber from the stopper can slip into the medication, contaminating the entire batch. Or maybe the person pulling the medication fails to use aseptic technique or uses a dirty syringe (the highly publicized hepatitis C outbreak in endoscopic centers throughout the Las Vegas area several years ago highlights that danger). So whenever possible, take manual manipulation out of the medication delivery equation by purchasing medications in final- or single-unit doses. That might not be the cheapest way to go, but it's definitely the safest.

2. Store smartly. Never store look-alike and sound-alike medications or medications that come in various strengths next to each other, and always attach warning stickers to containers containing high-alert medications. That means you should never store drugs alphabetically. Think about the possible missteps that could occur when you pull drugs for a case if, for example, 4 different strengths of ampicillin sit in adjacent bins. That puts drugs with the exact same name but various doses in a row, raising the risk of you grabbing the wrong bottle or replenishing the bins with the incorrect dose. Instead, stock drugs on shelves or in bins using a catalog system and note drug locations in a binder near the storage area. For example, place ampicillin 250mg in bin B1 and ampicillin 500mg in bin C2. You'll have to check the binder when pulling or re-stocking drugs instead of quickly — and perhaps absentmindedly — reaching for containers. Slowing down the drug pulling process improves your focus and adds a built-in check to medication delivery. To further avoid confusion, standardize the products you buy so each drug type is bought from a single manufacturer.

3. Label clearly. Remember that the average age of the perioperative nurse is inching closer to 50 years old, and that many of us wear bifocals. Make sure labels on medication bottles are large enough and printed with clear lettering so as to be easily read by all members of your surgical team.

Most medications sold today come with pre-printed labels, eliminating the need for secondary labeling at the sterile field. But when labeling at the sterile field is a must, be sure the labels and pens you use are also sterile. The person who opens vials should also label them; never pre-label syringes in order to save time during surgery as doing so means unintended medications could end up in the wrong syringe. Throw away all unused labels as soon as a case ends in order to avoid labeling confusion during subsequent procedures.

Get in the habit of labeling medications with both their brand and generic names. Doing so increases your understanding of what's being requested or delivered to the sterile field. It also increases the likelihood that you will reach for and ultimately deliver the correct drug since generic names include the drug's root suffix, which tips you off to which class it belongs to and, in turn, its properties.

4. Trust technology. Automated medication dispensing cabinets are incredibly effective at securing drugs, doling out correct doses and tracking supply usage. For larger facilities that can afford their hefty price tags, the technology decentralizes the pharmacy, putting medications close to where they are needed.

Design advancements over the years have dramatically improved the efficacy of automated storage. First generation models contained locking drawers that opened after users entered the required passcode. Once drawers opened, users were presented with an open-matrix design. They looked for needed meds in, say, bin B12, but nothing kept them from reaching for drugs in B13. So staff with access to the drawer also had access to each bin and every vial of medication. It was an effective supply management system, but far from fail-safe.

The latest automated storage cabinets boast designs that point you to the intended medication while keeping unintended vials behind lock and key. Here are a few of the most useful features.

• On-screen prompts guide you to the bin containing the correct drug. The bin lights up and its lid pops open, helping you to make the right decision. Some cabinets feature bar-code technology so you can confirm that you've pulled the correct drug, even after being prompted to the intended bin. In addition, the other bins in the drawer remain locked, making grabbing the incorrect vial more difficult. These levels of protection limit drug theft and improve pulling of the correct medication.
• Built-in alerts notify you when extra precautions need to be taken with the drugs you're requesting. For example, an on-screen prompt might remind you to ensure the patient you're pulling meds for isn't allergic to penicillin. In cases like that, automated alerts are a very good thing. However, alert fatigue can set in if users are asked to toggle through a series of overly cautious questions. For example, any nurse knows that codeine can cause constipation, so asking her if she's aware of this obvious fact before dispensing the drug is overkill.

Alert fatigue is a serious problem, so set built-in alerts to sensitivity levels that make sense for your experience and the type of medications you're dispensing. Alerts that sound too frequently can be frustrating, causing you to take shortcuts around the proper medication dispensing process and tune out alerts that truly could save a life. In fact, a physician at my hospital who was busy with paperwork once balanced a stapler on an automated supply cabinet's keypad in order to override the series of alerts that popped up. He received high marks for creativity, but failed miserably in my medication safety gradebook.

• Tracking software helps streamline drug storage by monitoring medication usage, charges and par levels, and sending alerts to the person in charge of ordering new supplies. In fact, my hospital outfitted the entire facility with automated cabinets using the charges they recouped by tracking medication use in our ORs.

Automated storage is wonderful, but approach it with an eye of caution. There's no guarantee that the right drugs find their way into the right bin when staff replenish the cabinets. (In another highly publicized case, actor Dennis Quaid's newborn twins overdosed on heparin when they were given doses 10 times stronger than the prescribed amount. Staff at Cedars-Sinai Medical Center in Los Angeles allegedly stocked an automated drug dispensing cabinet with the wrong doses.)

5. Improve communication. Always check drug names and doses against physicians' preference cards or orders each and every time you pull medications for a case. Take the card or order you used to pull the meds to the OR, where you'll verbally confirm the drug and dose with the recipient at the sterile field. Never lead recipients during verbal confirmations by asking, "This is ampicilllin 250mg, isn't it?" Instead, hold the bottle or vial up for inspection and ask them to read the label back to you. You can retrieve several products from storage for a case, but never pull meds for more than 1 case at a time, and always verbally confirm each medication you bring to the sterile field.

Preventable problem
The National Coordinating Council for Medication Error Reporting and Prevention says, in part, that a medication error is any preventable event that may cause or lead to patient harm while the medication is in the control of the healthcare professional. What does that mean in the real world? Medication mistakes are unnecessary and avoidable as long as you take the required steps to ensure that drugs are labeled clearly, stored securely and delivered correctly.