QUICK DRAW Label syringes immediately before or after filling them with medications.

Years later, he can't recount that day without choking up. "I don't think anyone would have suspected this little child — a very healthy child — on that given day, coming in for a very elective surgery, would not leave the hospital alive," says George McLain, MD, an anesthesiologist at Martin Memorial Health System in Stuart, Fla.

Medication vials were unmarked on the sterile field. The surgeon injected 9-year-old Ben Kolb with what he thought was lidocaine with dilute epinephrine. Unfortunately, sadly, it was concentrated 1:1,000 epinephrine.

"When we started doing CPR and the child did not come right back, I didn't feel a sense of panic, but a sense of dread," recalls Dr. McLain. "It was very difficult to see a child die right before your eyes."

Persistent problems
Don't think that devastating result could happen to you? Think again. Here are medication issues I've seen repeatedly in ORs while consulting with facilities for the Institute for Safe Medication Practices.

• Labeling. Clearly and completely label all medication containers and syringes. A pair of anesthesia partners at a hospital didn't label drugs in the sterile field because they had a system in place that involved drawing certain drugs into specific-sized syringes. During a presentation about the dangers of this practice, the anesthesiologists' faces turned white. They both relied on the same system for identifying medication, but did so with different medications. What would have happened if one of the partners couldn't complete a case and the other had to step in? Labeling systems needs to be standardized so everyone's on the same page and caregivers can provide safe patient care no matter which OR they step into and when during the case they intervene.

I've seen anesthesia providers properly label all syringes except those containing propofol, because they argued there was no other drug that resembled the milky white substance. But now Exparel and lipids are more common in ORs, and both look identical to propofol. Providers need to label all syringes prepared for use during procedures.

Never pre-label syringes, basins or bowls before filling them with drugs. Pre-labeled containers left on or near the sterile field can be inadvertently filled with the wrong medication by another caregiver. If you fill containers and syringes and label them immediately, odds are they will be labeled correctly. But if you pre-label them, the likelihood that they'll be filled with the incorrect medication increases as time passes before they're used.

Note the drug's name, dose and concentration on all labels. Avoid using potentially dangerous abbreviations. Spell out the word "units" because numerous medication errors have been caused by caregivers mistaking the shorthanded "U" for "0." Check out the ISMP's list of confusing drug names (ismp.org/tools/confuseddrugnames.pdf) and use tall-man lettering to differentiate these sound-alike and look-alike medications when labeling vials, syringes and storage bins.

SLEEP AID Always identify propofol, especially now that similar-looking medications are becoming more popular in the OR.

Several labeling solutions help ensure that staff administer the correct medications. Technology that generates labels containing required dosing information from the bar codes on drug vials is a good way to ensure labels are clear and accurate. Pre-printed, color-coded labels have a standardized look, contain required information and are easy to identify on the sterile field. Color-coded labels are a step in the right direction, but individual drugs in the same class can still have very different properties. Selecting the wrong beta-agonist, opioid or presser agent can still have devastating consequences, for example, so review color-coded labels to be sure you're administering the correct drug.

• Storage. Never store look-alike and sound-alike medications or medications that come in various strengths next to each other, and never store drugs alphabetically. Epinephrine and ephedrine are often stored next to each other, which creates the possibility of a potentially fatal mix-up.

Anesthesia trays are filled with many vials standing upright. You might find several different-colored dust caps in a single bin because the drugs are produced by 3 different manufacturers, especially now that many facilities face drug shortages. Relying on cap or label color, or the size or shape of a vial, is dangerous. As much as possible, standardize the products you purchase with the goal of avoiding the use of products that look very similar to others.

Automated dispensing cabinets and anesthesia carts help ensure that you access only the correct drug for administration. Anesthesia providers might push back against the use of the technology over concerns of wasting valuable time keying drug names and patient information into the system, and waiting for the correct storage drawer or bin to open. But isn't it worth a couple seconds for effective fail-safes to work? Besides, most anesthesia providers who use smart storage solutions soon realize the process doesn't take as long as they anticipated.

• Communication. Medication orders are rarely written down in the OR — it's an area where verbal orders are common. Unfortunately, so are communication breakdowns. A hospital once had a near-miss event involving an anticoagulant used for heparin-induced thrombocytopenia (HIT). After a patient was diagnosed with HIT in post-op, a hematologist gave a verbal order to the surgeon to start argatroban 2mcg/kg per minute. The surgeon heard it as an order for Orgaran, the brand name of a low-molecular weight heparin — not the drug you want to give to someone who's having a negative reaction to heparin.

The surgeon called the OR pharmacists to give the verbal order for Orgaran. The pharmacist questioned the dose, but not the drug, and called the hematologist to verify the order, who confirmed that the drug should be administered at mcg/kg per minute. They discussed the delivery rate, but didn't figure out they were talking about 2 different drugs.

To avoid communication-based mistakes in pre-op and the PACU, write down verbal medication orders immediately in patients' charts or enter them into electronic health records, and read what you documented back to the prescriber. Never write orders on scrap paper for rewriting them into the patient's record. Best practice is to record and read back orders immediately. When responding to verbal orders in the sterile field, where immediate documentation might be impossible, at least repeat the order and ask for verbal confirmation back.

Proactive prevention
Medication handling can easily drift from acceptable practices to at-risk behaviors. Several medication safety problems you're not aware of might be in your ORs because of the routines ingrained in your facility's culture. Take a look at your medication safety policies and ask What could go wrong?