Strategies for Better Medication Management

Pain Management

By: Joyce Wahr Wahr

Published: 10/14/2019

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Developing a comprehensive protocol for OR medication administration can fill holes that lead to errors — and uncover ones you knew nothing about.


Medication errors are all too frequent in the OR. A recent observational study identified an error in 5.3% of all anesthesia medication administrations — roughly 1 of every 20 — with about 80% of those errors deemed preventable. Why do so many medication errors still happen? Perhaps because, unlike all other locations in the hospital, the anesthesia provider is typically the only practitioner involved in determining what medication is needed, and then dispensing and administering that medication.

The problem of administration errors concerned our team so much that we researched all the available literature and organizational guidelines we could find that touch on medication safety. After whittling down all of the tips and findings we uncovered, we were left with 35 unique medication safety recommendations that all surgical facilities should consider in order to assess and correct vulnerabilities. (Our complete paper is at osmag.net/bZ7WgJ.) In this article, we'll briefly cover some of the most important ones.

  • Accurate patient information. Before administering medications in the OR, you need a complete, accurate medication reconciliation for the patient. All medications should be entered in a standard format in the patient's chart, and have a single location for recording medications administered across the surgical process, including pre-op and PACU, to avoid errors like double-dosing. Pre-op time outs should include the patient's weight, allergies and medication information such as which antibiotics have been given and when redosing would be needed. Anesthesia providers must be familiar about any patient condition or medication, such as allergies and drug-drug interactions, that could affect the types or dosages of medications to be administered.
  • Culture change. One of the most commonly mentioned recommendations in the literature and in guidelines is that every institution needs to have a non-punitive incident reporting system for the reporting and analysis of medication incidents, whether they harmed a patient or not. Medication safety requires a culture change, where there is respect and collaboration rather than judgment; you don't want people to feel badly about mistakes, nor do you want staff members to hesitate to report their colleagues for fear of getting someone else in "trouble" (unless it's a willful violation). Each institution should establish a voluntary, blame-free, non-punitive system for error incident reporting, analysis and intervention. No one begins their day by planning to make mistakes; similarly, it is highly unlikely that a provider who makes an error doesn't care, so they cannot be labeled as "careless." We are all subject to human vulnerabilities, experience fatigue, pressure and distractions, and are at risk of making an unintended error. Incident reporting and analysis should never seek someone to blame, but focus on how the system failed, and how vulnerabilities can be reduced. Create an environment where if somebody makes a mistake, that person feels comfortable reporting it to their superior; the end result should be that the entire team huddles to discuss how to prevent a similar mistake from occurring.

VISUAL AID Color-coded labels are safeguards against mixing up medications at the sterile field.   |  Pamela Bevelhymer, RN, BSN, CNOR

Teams should develop easily accessible written policies for medication safety, and stress their importance when orientating new staff. Adequate supervision, teaching and in-service training must be provided. Leaders should create and nurture an environment that helps people change their attitudes, habits, skills, and ways of thinking and working around medications. Once we recognize how patients are vulnerable to medication error, we should all be willing to improve our practices.

  • Pharmacy assistance. Medication in the OR requires close collaboration with your pharmacists. They should spend some time with you in the OR and understand how your ORs work. Pharmacists should be in control of the entire medication flow and need to clearly communicate any changes in the drugs they supply, especially when it results in vials that look alike, or when there is a change in a concentration provided.

A host of errors can occur when providers prepare their own syringes: mislabeling, vial swaps and incorrect dilutions. Prefilled syringes, or ones that are pharmacy-prepared, are generally safer, because pharmacists prepare syringes in a quiet location with fewer interruptions, and typically with safety checks built into that process.

  • Smart storage. Lookalike and soundalike medications can be a problem, so make sure such drugs are not stored in proximity to each other; place alert labels on containers that contain drugs that are similar-looking or similar-sounding to others in your formulary. Additionally, unique IV solutions like glucose, heparin, hypertonic, sterile water and epidural solutions should be stored separately from regular IV solutions.

Medication trays should be standardized across all anesthetizing locations, and the organization of the trays should be carefully thought out. Never arrange medications alphabetically; many facilities arrange meds in the order they will be used in the case. Label tray divisions clearly, and arrange the drugs so as to minimize confusion. Rarely used drugs in the OR, if they're needed for a case, should be kept in a unique location on top of the anesthesia cart, and removed at the end of the case.

Single-use vials are preferable; if a multi-dose vial is required, it can only be used for a single patient, and must be discarded at the end of the case. There should be no concentrated drugs on trays if possible, and if there are, they should contain an alert label, as should any high-risk drugs like insulin or heparin.

Keep medications used to place regional or neuraxial blocks on their own cart — absolutely keep them separate from IV meds. Cognitive aids, checklists, rescue protocols and infusion rate charts should all be on hand.

  • Clear identification. Every medication prepared for administration should be labeled with the name, date and concentration. Read and verify every vial, ampoule and syringe label before administration. Barcode technology with visual and auditory alerts or color-coded labels can be used to help providers easily identify the correct type or class of medication. Unfortunately, few ORs have implemented medication bar code scanning, even though it has been shown to reduce errors.

When labeling syringes, do not use abbreviations and watch out for "zero issues" — never use trailing zeroes (such as 5.0, which can be confused for 50) but always use leading zeroes (say, 0.5 instead of .5, which can be misread as 5). Never administer a medication in an unlabeled syringe.

Pass only a single med at a time into the sterile field, with 2 members of the surgical team checking and verifying that the correct agent is about to be administered. Verbal medication orders should be verified by speak-back, announced when given, and entered into the chart. When the procedure is completed, perform a clean sweep: discard all syringes and containers that aren't connected to the patient.

Looking to improve

Spend time assessing your medication administration workflow. Facilities often develop their own processes organically that fail to identify and correct all of the "error traps" that exist, often because staff hold onto the misguided belief that "this is the way we always prepare our medications." When you put together your medication safety protocol, find out where particular or potential errors are occurring and correct those issues. Standardize as much as you can to avoid inconsistencies and areas of confusion that can lead to errors. Try to make your process as airtight as you can and be sure to include as much documentation in the process as possible. And, above all, know that we will all make errors, and constantly be alert for situations where you or a team member might be at risk for making one. OSM

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