HARD STOP After our near miss, we decided to store local anesthetics in lidded specimen cups.

By all appearances, it was another busy vascular case involving numerous insertions of embolectomy catheters and injections of contrast dye. However, the physician assistant who typically worked alongside the surgeon was tied up in another room, so the surgical tech stepped in to help while also performing her regular duties. During the procedure, she turned to draw up contrast dye, but instead filled the syringe with a local anesthetic. Luckily, she realized her error immediately after injecting the patient and notified the surgical team. The anesthesiologist promptly administered lipids, and the patient was unharmed. The tech had followed the hospital's policies for the proper labeling and transfer of medications on the sterile field, but a potentially fatal error still came this close to occurring. Our review of the incident uncovered process improvements we needed to make, but also revealed plenty that went right to prevent patient harm. Here are 6 lessons we learned from the event that we hope you can incorporate into your medication safety efforts.

1. Create a hard stop. Put mechanisms in place to fix a faulty system that creates the possibility of human error. In our case, the surgical tech and the circulating nurse visually and verbally confirmed all medication delivered to the sterile field, including the contrast dye and local anesthetic. During our root cause analysis of the near miss, we decided that our medication labeling and handling policies weren't enough to prevent the surgical tech from drawing up the wrong drug, so we implemented a hard stop for whenever multiple agents are on the sterile field.

We now house local anesthetics in a lidded specimen cup instead of in an open Pyrex cup. The cover acts as a hard stop by creating a deliberate step in the process of drawing up meds; techs now pause for a second or two to consider if a local anesthetic is in fact the agent they want. We added additional specimen cups and lids to our procedure packs, so the surgical team has enough containers to implement the hard stop. We also taught every surgical tech about the new policy, had them sign off on their understanding of it and audited their practice for 6 months to ensure they complied with the new directive.

CONSTANT COMMUNICATION Circulating nurses and surgical techs must identify and confirm all medications that reach the sterile field.

2. Act quickly and decisively. Have a safety reporting system in place, so you learn about mistakes and near misses in real time. Funnel the reporting of events to the appropriate managers and administrations, so they can address the issue within 24 hours.

3. Review and reevaluate. On paper, no one did anything wrong when our near miss occurred. That was an eye-opening reminder of why you need to constantly reevaluate your policies and procedures to ensure your staff is doing everything they can to lower the risk of inadvertent errors. Don't wait for something to go terribly wrong before making needed process improvements. Have several leaders from the surgical unit sit on a committee that reviews your policies and procedures annually. Every error and near miss is a learning opportunity, so perform a root cause analysis as an interdisciplinary group on reported events, no matter how minor the mistake might seem. When that deep dive identifies the systemic cause of the event, develop a corrective plan that's agreed upon, actionable and monitored.

4. Limit distractions. The OR is a complex work environment where surgical team members conduct several medication handoffs amid numerous distractions: equipment noise, multiple conversations going on at once, outside interruptions and the surgeon's favorite music blaring over the room's sound system. The surgical team doesn't have to work in silence, but it's important to limit factors that can divert their attention from the task at hand. For example, agree on playing music at a reasonable volume, keep conversations focused on clinically relevant topics, refrain from speaking during critical moments of the procedure and limit foot traffic into and out of the room.

5. Brush up on the basics. Hard stops are needed to address specific medication safety issues, but it's also important to follow standard labeling and handling protocols. In general, the circulating nurse verbally verifies with the surgical tech the solution, strength and expiration date of the medication she's delivering to the sterile field. The tech then visually confirms that information on the container's label before filling a similarly labeled syringe. During the procedure, the surgeon asks for the medication, the tech hands him the labeled syringe as she states which agent she's passing and the surgeon confirms the contents as he receives the syringe.

Consider using pre-printed labels for commonly used drugs to provide the surgical team with accurate, easy-to-read information. Plus, the information on pre-printed labels remains legible even after being hit with fluids that often splash onto the sterile field. The same can't be said for handwritten labels, which can smear when wet, but which are still needed to identify seldom-used agents. When filling out handwritten labels, be sure to note the medication's name, strength and dose.

Color-coded labels provide staff with a quick and easy way to identify the contents of a syringe or container, but that benefit is also a potential drawback. We've eliminated the use of color-coded labels, because we found that staff members were relying on the color of labels when retrieving needed medications instead of rereading and rechecking the information on conventional labels.

6. Encourage sharing. Reporting adverse events is an effective way to prevent similar mistakes from occurring. Make sure staff members understand that their reporting of errors and near misses will not be met with punishment (unless, of course, their actions were a careless and intentional disregard for patient safety).

The tech who accidentally filled the syringe with local anesthetic felt comfortable speaking up, which can be a difficult thing to do, because she knew we'd support her willingness to own the error. She showed courage in putting patient safety above her own pride, but she also knew our response would be a non-punitive investigation to protect future patients from potential harm.

It's also a good idea to share the lessons learned from near misses and mistakes at daily morning huddles. There's no better way to raise awareness than to have staff members share their insights from a real-life event — when the details are still fresh in their minds. OSM