It's no secret that poor documentation, dangerous abbreviations and unlabeled syringes can lead to harmful medication errors or adverse drug events. What's surprising is how often they occur in surgery. See if your nursing and anesthesia providers can spot the medication error in each of these 6 real-life photos. Let's start with a common drug charting infraction: trailing zeros and naked decimal points.

• No trailing zeros. Is this 1 mg or 10 mg of midazolam? One of the most dangerous and frequent error-prone abbreviations is the trailing zero after a decimal point — 1.0 mg in this example. The correct entry would simply be "1 mg." If you don't see the decimal point, 1.0 could be administered as 1 mg or 10 mg — admittedly a high dose, but a ten-fold dosing option is feasible with midazolam. Regardless, never add a trailing zero.

Similarly, shield your eyes from naked decimal points (one without a leading zero). Never write a dose as .5 mg, for example. For clarity, always apply a lead zero before a decimal point when the dose is less than a whole unit — 0.5 mg in this example. If you don't see the decimal point, you can easily interpret .5 mg as 5 mg.

• Is that all there is? These labels are missing so much required information. The expectations for the labeling of syringes call for more explicit detail: drug name, strength, date, time and the preparer's initials. A sticker that says "Vanco" does not a label make.

• Way-in-advance drawing of syringes. Failing to provide the required labeling information is just one of the problems with these syringes of propofol we spotted in an endoscopy center. When were they filled? Drugs should be drawn as close to the time of administration as possible — and administered within 1 hour of preparation. If a drug is not used immediately, your staff needs to label, date and time it. If it's not used within 1 hour of the time it's drawn up, they need to discard it.

• 2 mg or 11 mg? We know this is 2 mg, not 11 mg of midazolam, but it is a poor method of charting sequential dosing on the anesthesia record. Further, the anesthesia record should be explicit, with "milligramage" noted. In this case, we would be looking for midazolam mg and remifentanil mcg. Preprinting those drugs and strengths or units of administration would help clarify the anesthesia record.

• No outside medications. Using a patient's "own medications" is not recommended, except in a few extenuating circumstances, such as a unique inhaler. If a patient brings medications into the facility, they should only be administered on a valid and documented order of a licensed prescriber. Your facility should identify the medications and validate their integrity as best as possible. Outside medications are best self-administered outside of the OR under the observance of a nurse or physician. Appropriate documentation in the medical record is required.

• Keep under wraps. Unwrap syringes as close to the time of need as possible, so that you eliminate the chance that you pick up a used syringe that is intermingled with new ones.

Dangerous drug abbreviations

The Institute for Safe Medication Practices (ISMP) has compiled abbreviations, symbols and dose designations that are frequently misinterpreted and involved in harmful medication errors. Share the "List of Error-Prone Abbreviations" (osmag.net/XCjuZ6) with your nursing and anesthesia providers. OSM