READ THE LABEL Medications that reach the sterile field must be clearly and properly marked.

A pain doctor gives a pre-op verbal order for 500 mg of IV cefazolin, but the nurse he directs the order to instead administers 500 micrograms of fentanyl because she didn't hear him correctly, and she is too intimidated to question the order. This real-life communication breakdown is just one example of the medication errors that continue to occur in ORs across the country. You might not be able to completely prevent medication mishaps from occurring, but you can put systems in place to ensure errors don't result in patient harm.

Learn and improve
There are 2 ways to approach medication safety improvement. The first is a "person approach," in which you look at medication errors as occurring due to human imperfections: forgetfulness, poor motivation, carelessness, inattention or even negligence. Solutions from this perspective include disciplinary actions and blaming individuals. The second and superior approach is a "systems-based approach." Errors are viewed as the end result of imperfect systems.

Even the best systems fail. It's up to you to devise solutions based on changing conditions, instead of focusing on changing humans. How? Implement barriers and safeguards to help prevent errors. When errors do occur, assess how and why the system failed instead of focusing on which individual erred.

Anesthesia providers and nurses administer most medications. When errors occur, ask representative leaders of both groups to meet as a quality improvement committee to assess the conditions that made the error possible and to work together to eliminate these conditions.

Was the error due to look-alike, sound-alike (LASA) medications? For example, if an anesthesia provider administers a dose of undiluted intravenous phenylephrine when he intended to administer a dose of intravenous atropine, a systems approach may reveal that the 2 ampoules looked alike and were stored in adjacent locations in the anesthesia drug drawer. A quality improvement would include changing the vendor for one of the medications, so that the ampoules do not look similar, or moving the undiluted phenylephrine ampoules to a drug locker removed from the operating room to reduce the likelihood of a mistaken administration.

EASY ON THE EYE Color-coded labels reduce risk of medication mix-ups.

A specific challenge to the surgical arena is that anesthesia providers both choose and administer medications without input from a second healthcare professional. An anesthesia provider administers multiple potentially harmful medications to patients every day, medications he chooses without an order and without checks or balances. He can draw up a wrong ampoule, label a syringe incorrectly or administer a drug from the wrong syringe with minimal interference from other professionals. This makes a systems approach to eliminating anesthesia provider errors more difficult to set up.

Labels leave no doubt
Ensure each drug label on each syringe or container that reaches the sterile field notes the drug, strength, date, time drawn and the drawer's initials. Although best practice is to note the expiration date on ampoules as well, busy anesthesia providers rarely check this on the dozens of ampoules they handle each day. They trust that the facility's staff regularly screens drug supplies and eliminates expired ampoules. This makes the management and monitoring of your medication inventory critically important.

Use "Tall Man Lettering" to highlight distinctive syllables in similar looking drug names. Clearly write information on labels using a ballpoint pen or felt-tip marker that won't smudge or run. To eliminate risk of misreading handwritten labels, consider using pre-printed labels color-coded by drug classifications: induction agents in yellow, benzodiazepines in orange, muscle relaxants in fluorescent red, narcotics in blue, vasopressors and hypotensive agents in violet, and local anesthetics in gray. Peel-off labels on vials can be applied to single-use syringes when the vials' contents are drawn. Drug names should still be visible on the vials after the peel-off labels have been removed.

Whenever possible, leave drugs in their already correctly labeled ampoules until it's time to administer them. Prepare a lineup of empty syringe-needle combinations, and use one each time you need to open an ampoule and administer a drug. Whenever possible, transfer the dose from the ampoule to the patient's IV immediately, and skip the step of labeling a syringe. When less than a full ampoule is administered, leave the remainder of the drug inside the already labeled ampoule. Save all used ampoules until the end of the case in case confusion arises about which drugs were administered.

ROOT CAUSES
Why Medication Errors Happen

IN GOOD HANDS Standardized protocols and uninter-rupted focus during critical stages of medication handling reduce risk of errors.

Here's the ideal method for administering medications on the sterile field. The circulating nurse checks the label on the bottle and correctly identifies the medication, the volume and the concentration. She then opens the vial and pours it into a container on the sterile field. The surgical tech draws the medication into a syringe and labels the syringe by directly reading and copying the information off the vial label. This usually occurs prior to the surgical case. The surgical tech then communicates the contents of the syringe to the physician just before administration. That process can break down, because of these common issues:

• Non-standardized care and resistance to checklists. At a recent lecture at Stanford University about avoiding medical mistakes, the repeated mantra was "variation is the enemy of good." Your surgical team must strive to standardize patient care as much as possible. This includes the use of standard clinical practices and checklists. Medication checklists should include meticulous details about potential patient allergies.
• Communication silos. The theory is that employees and medical professionals make fewer errors if they work without distraction from other sources or departments. In terms of medication safety, this focused silo approach should occur when medications are drawn up, labeled or administered.
• Outside pressures. Data show that more errors occur if individuals are rushed or distracted. For example, an anesthesia provider instructed to induce patients and turn over cases with great rapidity is more apt to make a medication error caused by a syringe or ampoule swap. Production or economic pressure should never negatively affect clinical performance.

— Rick Novak, MD

DRUG STORE Automated storage solutions direct staff to intended medications.

Organized, secured storage
The "big three" medications at risk for safety errors are opioids, insulin and anticoagulants, according to Darryl S. Rich, PharmD, MBA, FASHP, a medication safety specialist at the Institute for Safe Medication Practices. Insulin is almost never used at facilities that host ambulatory cases, because if a patient has hyperglycemia significant enough to require insulin, the case is often postponed until the diabetes is better controlled. Likewise, anticoagulants are almost never needed in an outpatient setting. Narcotics, however, pose a serious risk. Patients with significant comorbidities, extremes of age or high body mass index, or those receiving concurrent sedatives, are at increased risk if given an overdose or an incorrect dose. The management of narcotics is therefore a common focus of quality improvement initiatives.

Supplies and quantities of narcotics and scheduled drugs must be secured and controlled in all settings, either by 2 signatures from nurses or physicians at the beginning and end of the day, or by the use of automated storage units.

Access to narcotics and controlled drugs should be limited to nurses, anesthesia providers and pharmacists. Conduct a correct count at the beginning and end of each surgical day to document that no drugs have been stolen or lost. It's still possible for staff members to chart the administration of drugs, when in fact they've pocketed the substances for personal abuse. It's difficult to prevent such theft by stealthy and motivated individuals driven by addiction.

MEDICATION MONITOR Limit access to controlled substances and document their daily counts.

Propofol is still non-controlled at most facilities, and the theft and illicit use of the drug is a threat and concern. Ideally, the number of vials and the number of milligrams used for each patient should be quantitated and rectified with supplies at the end of the day, just as narcotics are tallied. This security step isn't currently mandated, but don't be surprised if it is in the future.

Screen your drug drawers for look-alike and sound-alike drugs. Don't purchase or store drugs with look-alike labels. If a look-alike drug ampoule arrives, return it and seek a drug from a different vendor. If no alternate vendor exists, place an orange warning label on similar looking ampoules to alert staff and anesthesia providers to double-check the contents before use.

Operating room carts should contain only drugs for daily non-emergent use. Store emergency ACLS drugs in immediate-use syringes separately from routinely used drugs. Finally, don't stock harmful medications such as epinephrine, undiluted phenylephrine, potassium chloride, nitroprusside, or insulin in general storage locations.