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Current Opinion inCurrent Opinion in

AnesthesiologyAnesthesiology

Euroanaesthesia 2019

How to improve patient safety in the operating room anesthesia work areaChairman: Professor Xavier Capdevila

Medication Errors in the OR: Causes and EpidemiologyDr. Sven Staender

Medication Safety: Insights from an Expert Pharmacist Dr. Edith Dufay

Strategies to Prevent Medication ErrorsProfessor Joyce Wahr

Disclaimer: The statements and opinions contained in the meeting reporter of the EUROANAESTHESIA CONGRESS 2019 are solely those of the individual authors, contributors and do not necessarily refl ect those of the Journal or the Editors-in-Chief of Current Opinion in Anaesthesiology. The meeting reporter is being posted online without being peer-reviewed by Current Opinion in Anaesthesiology journal

Supplement in collaboration with Aspen Pharma. Both the symposium and the report have been supported by Aspen Pharma.

MEETING REPORTER

CURRENTOPINION How to improve patient safety in the operating

room anesthesia work area
At the 2019 Euroanaesthesia Congress in Vienna,Austria, Professor Xavier Capdevila chaired a sym-posium supported by Aspen with Dr. Sven Staender,Dr. Edith Dufay, and Professor Joyce Wahr. Thediscussion focused on the types of medication errorsthat occur in the operating room (OR) and specificstrategies to improve patient safety. These strategiesinclude facilitating closer cooperation betweenphysicians and pharmacists, fostering a culture ofteamwork in the OR, and implementing technolo-gies and process changes designed to prevent orreduce medication errors.
THE IMPORTANCE OF PATIENT SAFETY –PROFESSOR XAVIER CAPDEVILA

Chairman:Professor Xavier Capdevila,

MD, PhD, head of the Departmentof Anesthesiology and CriticalCare at Montpellier UniversityHospital in Montpellier, France,and current president of theFrench Society of Anesthesia andCritical Care (SFAR).

Professor Xavier Capdevila
introduced the session by explaining that patientsafety is probably the most important topic foranesthesiologists and intensivists. And the risk ofmedication errors in the OR is not often discussed.Approximately 13–14 million patients are harmedeach year as a result of medication errors, at a cost ofbillions of dollars. Understanding the root causes ofmedication errors in the OR and building a safetyculture in which medication errors are reported andanalyzed are the first steps toward implementingsolutions to prevent medication errors and ensuregreater patient safety.
0952-7907 Copyright � 2019 Wolters Kluwer Health, Inc. All rights rese

MEDICATION ERRORS IN THE OR:CAUSES AND EPIDEMIOLOGY –DR. SVEN STAENDER

Speaker:
Dr. Sven Staender, PD, Dr.
Med, head of the Department ofAnaesthesia and Intensive CareMedicine at Manndorf UniversityHospital the Regional Hospitalin Maennedorf, Switzerland, andvice chairman of the EuropeanPatient Safety Foundation.

Dr. Staender gave the first lec-
ture of the session, focusing on the types of medica-tion errors that occur in the OR. Various categories ofmedication errors occur along the patient journey,from the time of the initial prescription, throughdrug selection, calculation, preparation, and admin-istration. With regard to the initial prescription,handwritten prescriptions are often difficult to deci-pher and easy to misinterpret, with different termi-nology used for units, decimals, and dosageabbreviations. Mistakes can also occur when prescrip-tions are ordered by phone, though read-back canhelp ensure that the listener is getting the correctinformation. Other causes of medication errorinclude incorrect selection of look-alike/sound-alikedrugs, dose calculation and dilution errors, labelingerrors, incorrect dose or administration site selection,improper flushing, and lack of hygiene.
Look-alike and sound-alike (LASA) medications

Medication errors can happen at the point of drugselection, when the user picks the wrong medication,or the wrong concentration of the correct medica-tion. Selection errors often occur as a consequence oflook-alike or sound-alike medications. Dr. Staendershared an image of a typical drug cart in the OR thatappears organized, but could nevertheless lead toincorrect selection of medication within a high-stressenvironment (Figure 1). The picture showed onecompartment containing different medications thatare difficult to identify due to similarities in ampouledesign, size and color. In addition to the risk ofconfusion caused by the similar design of theampoules, labeling information requirements canreduce the font size and readability of the labels,particularly on small ampoules, making medicationidentification more challenging.

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Figure 1. This is the slide of Dr Staender. Example of an organized medication cart, though one that is still prone tomedication selection errors. Image published with permission from Dr. Staender and the European Patient Safety Foundation.

Euroanaesthesia 2019 - How to improve Patient Safety in Operating Room anaesthesia work area - Supplement from Aspensymposium during Euroanaesthesia 2019. Both the symposium and the report have been supported by Aspen Pharma.

Dose calculation and medication labeling

Another point of medication error is at the time ofdrug calculation. Calculations are often requiredwhen a medication must be reconstituted to reach aspecific dilution; in many cases, this process can becomplex. Dilution errors are seen more often in pedi-atric patients, where a ‘‘factor-10 error’’ in medicationdosing has been noted across various medications.Errors in dose calculations can happen because of amedication’s labeling, which can be difficult to read,particularly when prepared medications are hand-labeled with the name and the concentration. Inaddition, incorrect label placement over the medica-tion name and dose on prepared syringes or bags canmake it challenging to verify dosing. Likewise, unla-beled containers of liquid in the surgical field can leadto misidentification of medications and increase therisk of errors that affect patient safety.

Medication contamination: the case ofpropofol

Medication errors can also be introduced at thepoint of medication administration. In additionto errors in dosing, administration site selection,and improper flushing, patient safety during medi-cation preparation can be compromised by poorhygienic practice. The importance of hygiene wasillustrated in a study of propofol, which is providedin a nutrient-rich emulsion that is easily contami-nated and facilitates the growth of microorganisms.In that study, concentrations of various bacterialcontaminants increased within a 3-way stopcocksystem 48 hours after propofol administration, evenwhen there was no visible propofol in the line afterflushing (Figure 2). The study results suggested that

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flushing is not sufficient to prevent contamination,and that it is not safe to assume the risk is decreasedwhen there is no visible propofol in the line. Stricthygienic practices are recommended when manipu-lating propofol, including using two three-way stop-cocks with the proximal stopcock used for delivery,so that the distal stopcock and line can be discon-nected and the proxima (with ‘‘contaminated’’ Pro-pofol) stopcock discarded after the procedure.

Epidemiology of drug errors

Although medication errors are a significant problemin the OR, Dr. Staender explained that only a fewrobust studies have evaluated medication error inci-dence and prevalence. Data from the United StatesPharmacopeia (USP) in 2003 indicate thatprescribingerrors and improper dosing were the most commontypes of medication errors. Yet the impact of theseerrors varies: an analysis of data from USP MED-MARX, a voluntary, anonymous reporting system,found that 82.7% of medication errors do not actu-ally reach the patient or cause harm (e.g., error, noharm). Several studies have analyzed the incidence ofanesthetic administration errors using data fromreporting systems. The results show incidences rang-ing from 1 in 133 patients to 1 in 450 patients.However, the data from reporting systems shouldbe interpreted with caution because of the bias intro-duced by voluntary reporting. Indeed, observationalstudies have revealed very different medication errorincidences. Merry et al reported a drug administra-tion error rate of between 1 in 9 and 1 in 11 admin-istrations. A more recent study by Nanji et al reporteda medication error and/or adverse drug event rate of1 per 20 perioperative medication administrations.

Figure 2. This is a slide of Dr Staender. Bacterial growth (measured as colony-forming units) over time in three-way stopcocksused in propofol administration. Reprinted with permission from Cole DC, et al. Anesth Analg. 2015;120(4):861-7.


The impact of medication shortages

Various factors contribute to medication errors,from disorganized or stressful workplace condi-tions to a lack of communication and coordinationof the OR team. Workplace pressures are com-pounded by a trend toward higher procedural vol-umes and a rise in medication shortages. In a surveyconducted in 38 countries by the European Associ-ation of Hospital Pharmacists, approximately 35%of respondents reported daily medicine shortagesand 38% reported weekly shortages. Shortagesof anesthetic agents in particular have increasedfrom approximately 30% in 2014 to over 40%in 2018. Medication shortages most often leadto substitution with equivalent drugs and drugrationing, both of which increase the risk of errors.Medication shortages also increase costs for hospi-tals and pharmacies, because the substitutedmedications are often more expensive. ACanadian study reported that shortages of anes-thetic agents most often lead to modificationsof anesthetic techniques, administration of lessfamiliar drugs, and postponement or cancellationof procedures.

‘‘Anesthesiology is the safety discipline in healthcare.’’ – Dr. Sven Staender

Dr. Staender concluded that anesthesiologistsare critical advocates for patient safety; theyneed to speak up when processes are dangerousand encourage teams and organizations to recon-sider workflows and discuss approaches to mini-mize medication errors and maximize patient


safety. By working together with pharmacists,administrators, and companies, anesthesiologistscan help find solutions that will limit the risk ofmedication errors.

References

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Cole DC, Baslanti TO, Gravenstein NL, Gravenstein N.Leaving more than your fingerprint on the intravenousline: a prospective study on propofol anesthesia andimplications of stopcock contamination. Anesth Analg.2015;120(4):861-7.

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Cooper JB, Newbower RS, Kitz RJ. An analysis of majorerrors and equipment failures in anesthesia manage-ment: considerations for prevention and detection.Anesthesiology. 1984;60(1):34-42.
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European Association of Hospital Pharmacists. 2018Medicines Shortage Survey. file:///C:/Users/stace/Downloads/report_medicines_shortages2018.pdf.Accessed August 2, 2019.
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Hall R, Bryson GL, Flowerdew G, Neilipovitz D, Gra-bowski-Comeau A, Turgeon AF; Canadian PerioperativeAnesthesia Clinical Trials Group. Drug shortages inCanadian anesthesia: a national survey. Can J Anaesth.2013;60(6):539-51.
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Koren G, Barzilay Z, Greenwald M. Tenfold errors inadministration of drug doses: a neglected iatrogenicdisease in pediatrics. Pediatrics. 1986;77(6):848-9.
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Kozer E, Scolnik D, Keays T, Shi K, Luk T, Koren G. Largeerrors in the dosing of medications for children. N EnglJ Med. 2002;346(15):1175-6.
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Llewellyn RL, Gordon PC, Wheatcroft D, Lines D, ReedA, Butt AD, Lundgren AC, James MF. Drug administra-tion errors: a prospective survey from three SouthAfrican teaching hospitals. Anaesth Intensive Care.2009;37(1):93-8.
d. www.co-anesthesiology.com 3


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Merry AF, Webster CS, Hannam J, Mitchell SJ, Hender-son R, Reid P, Edwards KE, Jardim A, Pak N, Cooper J,Hopley L, Frampton C, Short TG. Multimodal systemdesigned to reduce errors in recording and administra-tion of drugs in anaesthesia: prospective randomisedclinical evaluation. BMJ. 2011;343:d5543.

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Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW.Evaluation of perioperative medication errors andadverse drug events. Anesthesiology. 2016;124(1):25-34.
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Pauwels K, Simoens S, Casteels M, Huys I. Insights intoEuropean drug shortages: a survey of hospital pharma-cists. PLoS One. 2015;10(3):e0119322. doi: 10.1371/journal.pone.0119322. eCollection 2015.
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Santell JP, Hicks RW, McMeekin J, Cousins DD.Medication errors: experience of the United States Phar-macopeia (USP) MEDMARX reporting system. J ClinPharmacol. 2003;43(7):760-7.
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World Health Organization. Patient safety. https://www.who.int/news-room/facts-in-pictures/detail/patient-safety. Accessed August 2, 2019.
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Zhang Y, Dong YJ, Webster CS, Ding XD, Liu XY, ChenWM, Meng LX, Wu XY, Wang DN. The frequency andnature of drug administration error during anaesthesiain a Chinese hospital. Acta Anaesthesiol Scand. 2013;57(2):158-64.

MEDICATION SAFETY: INSIGHTS FROM ANEXPERT PHARMACIST – Dr. EDITH DUFAY

Speaker:
Dr. Edith Dufay, PharmD,
Head of pharmacy at the CentreHospital of Luneville in Lune-ville, France

Dr Dufay discussed theimportance of opening a dia-logue between anesthesiologyand the pharmacy. Becausepractical solutions need to be
developed to recognize, report and prevent medi-cation error in the OR. The ultimate goal is tooptimize patient safety. The reduction and preven-tion of medication errors relies on a holistic, globalapproach to patient care, in which specialists crossdisciplinary lines to work as a team in the OR. Thedelivery of patient-centered care can be interruptedat several points along the patient’s journey—atadmission, transfer, and discharge—and commu-nication and information sharing between the ORteam and the pharmacist is critical at each of thesepoints to reduce medication errors.
REMED, a project to review and preventionthe occurrence of medication errors

Dr. Dufay presented the Review of Errors in Medica-tion project, called REMED, in which pharmacistsconvene a meeting of all healthcare providersinvolved in a medication error to engage in a collec-tive, retrospective, blame-free, in-depth analysis ofthe error. By design, medication errors are consid-ered to be unintentional, such that the healthcareproviders involved are not only secondary victims ofthe error but also a valuable source of informationthat can be used to improve the medication systemto avoid future errors. During the REMED meeting,a methodology with 11 tools is used to fully analyzethe error, its causes, associated risk, and potentialsolutions. One of these tools is a comprehensivecharacterization of the medication error based onsix features (Table 1).

https://www.who.int/news-room/facts-in-pictures/detail/patient-safety



Table 1. Six Features of Medication Errors Analyzed in

the REMED Meeting

1 Healthcare productinvolved

Medication, deviceProduct name, lot, vendorDoseRoute of administration

2 Type of error PatientOmissionSelectionDosageAdministrationTiming

3 Stage at which theerror was detectedand intercepted

Potential error - interceptedbefore reaching thepatient

Actual error - identifiedafter reaching the patient

4 Seriousness of the error MinorSignificantMajorCriticalCatastrophic

5 Potential risk of themedication error if ithad not beenintercepted

MinorSignificantMajorCriticalCatastrophic

6 Stage at which themedication error wasidentified

Patient identificationPrescriptionDispensationAdministrationMonitoringInformationLogistics

This is extracted from Dr Dufay’s slide.


An important benefit of the REMED medicationerror characterization methodology is that it bringstogether the team of healthcare providers, each withtheir own perspectives, and encourages them to discussthe error objectively. Specialists must communicateacrossdisciplines to findacommonlanguageandreacha consensus. For example, the REMED characterizationmethod was used to analyze a medication error thatoccurred during a peridural analgesia procedure on apregnant woman. The team identified multiple factorsthat ledtotheerror,whichoccurredatmultiple levels—from confusion caused by look-alike medications to alack of established protocols for a specific procedure inthe OR. Once the six features of the medication errorwereagreedupon, theteamwasable to identify therootcauses and develop specific improvement actions.

At Dr. Dufay’s institution (Luneville HospitalCenter), the REMED has been positioned as a processthat is as important as the morbidity and mortalityreview (MMR). The REMED is also used to help theLuneville Hospital Center to help report casesof medication errors to healthcare agencies in anunbiased manner.


Medication reconciliation

While medication reconciliation is one of the mostpowerful methods to intercept and prevent medicationerrors, it continues to be a challenging task for manyorganizations. Medication reconciliation takes intoaccount, at the time of a new prescription, all the medi-cations that a patient is taking and has been prescribed.Implementation of medication reconciliation requirescoordination of information sharing between multiplecareprovidersandthepatientat the transitionpointsofadmission, transfer, and discharge.

A recent study, initiated as part of the WorldHealth Organization’s High 5 Initiative to implementmedication reconciliation in 5 countries, collecteddata on medication errors intercepted by the phar-macist through medication reconciliation forpatients 65 years of age or older at the time of admis-sion to the emergency department. The potentialseverity of the consequences had the prescriptionbeen given to the patient were also assessed. Of1677 medication errors intercepted and corrected,most (69.1%) were minor, but 18.8% were significantand 5.2% were major or catastrophic.

To reduce medication errors for patients admittedthrough the emergency department, healthcare pro-viders are encouraged to report the medication historyin the electronic medical record (EMR) so that it can becommunicated to the pharmacist and used for medi-cation reconciliation and to set up prescription orders.For patients with a planned surgical intervention,providers can work with community pharmacists toreceive a medication history prior to hospitalizationand discuss any potential medication errors.

Pharmacists in the OR

Assigning pharmacists to the OR can facilitate com-munication between the pharmacist and anesthesi-ologist so that they can more quickly discuss andaddress medication errors. As a member of a multi-professional team within the OR, the pharmacistwould order medications directly from the OR ratherthan through the pharmacy, and work closely withthe anesthesiologist to prevent drug errors, ensuringthe right medication is given to the right patient forthe right intervention. In the OR, one of the mostcommon consequences of drug errors is a delay of theintervention. Assigning pharmacists to the OR canreduce delays in surgical interventions, with a signif-icant cost savings and sustainability (Figure 3).

Dr. Dufay closed by re-iterating that cross-disci-plinary cooperation and communication are signifi-cant challenges in preventing medication errors.Anesthesiologists are encouraged to seek out oppor-tunities to change processes to improve patientsafety, and to include the pharmacist in those efforts.

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Figure 3. This is a slide from Dr Dufay. Improvements in workflow with inclusion of pharmacists or pharmacy technicians inthe OR team. Image published with permission of Dr. Edith Dufay.


References

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Dufay E, Doerper S, Michel B, Roux Marson C, GrainA, Liebbe AM, Long K, Tournade N, Allenet B, BreilhD, Alquier I, Michelangeli ML. High 5s initiative:implementation of medication reconciliation inFrance, a 5-year experimentation. Saf Health.2017;3(6). doi: 10.1186/s40886-017-0057-6

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Dufay E, Morice S, Dony A, Baum T, Doerper S,Rauss A, Piney D. The clinical impact of medication

reconciliation on admission to a French hospital: aprospective observational study. Eur J Hosp Pharm.2016;23(4): 207-212.

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Risk Management Analysis Committee of the FrenchSociety for Anesthesia and Critical Care (SFAR); FrenchSociety for Clinical Pharmacy (SFPC). Preventing medica-tion errors in anesthesia and critical care (abbreviatedversion). Anaesth Crit Care Pain Med. 2017;36(4):253-258.


STRATEGIES TO PREVENT MEDICATIONERRORS – PROFESSOR JOYCE WAHR

Speaker:
Professor Joyce Wahr, MD,
Department of Anesthesiology atthe University of Minnesota ofMinneapolis in Minnesota, UnitedStates

Professor Wahr described thatwhile medication errors are top ofmind for anesthesiologists, therecommendations available inthe literature to prevent medica-
tion errors are based primarily on expert’s opinion.
Also only two randomized controlled trials,published by Merry et al., have tested a system ofmedication delivery (SAFERSleepTM) for reducingmedication errors in the OR. The system includesa customized medication tray and medication cartdrawers designed to promote a well-organized work-space and aseptic technique. And the system alsorecommends to use:

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Pre-filled syringes for commonly used anestheticmedications

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Large, legible color-coded drug labels
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A barcode reader linked to a computer, speakers, andtouch screen to provide automatic auditory and visualmedication verification
The results of these trials, presented by ProfessorWahr, showed that in 1075 cases, the overall meanrate of drug errors was 9.1% with the new system (1in 11 medication administrations) and 11.6% withconventional methods (1 in 9 medication admin-istrations) (P¼0.045). The study was repeated in 80simulated cases in which ‘‘error traps’’ were intro-duced (e.g., purposefully putting the wrong vials inthe medication trays) to test the system’s ability tointercept the errors. The mean rates of error were6.0% for the new system vs. 11.6% for conventionalmethods (P¼0.001).

Beyond these two trials, recommendations forreducing medication errors are based on systematicreviews and consensus documents. In 2004,Dr. Jensen and colleagues reviewed 98 studies onmedication errors and assigned points based on thequality of the study. This review led to 1 general and5 specific recommendations, which focused primar-ily on labeling, organization, and using a two-per-son check. In 2010, the Anesthesia Patient SafetyFoundation released a set of consensus recommen-dations based on input from approximately 100professionals. Recommendations fell into 4 majorcategories (Figure 4):


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Standardization

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Technology
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Pharmacy/prefilled/premixed
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Culture
Review of strategies to improve patientsafety

In 2013, Professor Wahr revisited Dr. Jensen’sapproach by conducting a systematic review ofstudies on medication error and medication safety,specifically focused on anesthesia medications inthe cardiac OR. The review included 186 articles, ofwhich 111 were excluded (single-author case stud-ies), and points were awarded for the strength ofthe study. The review also included currently avail-able recommendations (from the Institute for SafeMedication Practices in Canada, the AnesthesiaPatient Safety Foundation, and the Institute forHealthcare Improvement) and guidelines fromthe Centers for Disease Control, Association ofPeri-Operative Registered Nurses, and the Ameri-can Society of Healthcare Pharmacists. For eachrecommendation, the number of times the recom-mendation was made and the total number ofpoints given to the studies in which those recom-mendations were made were reported. Comparedto the recommendations compiled in 2004,Dr. Wahr and colleagues found a greater emphasison recommendations related to improving theculture and working environment within theOR, followed by recommendations regardinglabeling. A modified Delphi analysis generateda list of the top recommendations for reducinganesthesia medication errors in the cardiac OR(Table 2).

The recommendations echo many of the samethemes noted by Drs. Staender and Dufay in theirlectures, such as the importance of fostering a cul-ture of safety in the OR so that the anesthesiologistfeels comfortable reporting errors, and the criticalrole of the pharmacist. In the area of medicationadministration, recurring themes also includedmedications ‘‘prefilled, compounded, and dilutedby pharmacy’’ and implementing a two-personcheck.

While many of the recommendations regardingcart organization have already been put into prac-tice, such as using single-use vials and removinghigh-risk medications, other recommendationsthat could be implemented easily include color-coded labeling of every syringe and container andlabeling of all routes of administration (IV, arterial,neuraxial), especially those with a stopcock inthe line.


Figure 4. This is extracted from the slide of Professor Wahr. Anesthesia Patient Safety Foundation 2010 consensusrecommendations for improving medication safety in the OR. Reprinted with permission from the Anesthesia Patient SafetyFoundation.


Building a culture of safety‘‘Unlike other areas of the hospital, anesthesiolo-gists are the only ones who prescribe, dispense (takeit out of the drawer), prepare (put it in a syringe), andadminister medications without a check.’’ –Professor Wahr

While anesthesiologists work within a team inthe OR, in the area of anesthetic medications, team-work is not emphasized. Assigning a pharmacist tothe OR is one approach to improving medicationsafety, and anesthesiologists are also encouraged to‘‘develop a questioning attitude’’ and to speak up ifsomething does not make sense.

In the OR, the anesthesiologist works with bothanesthesia medications and machines, but manymore advances have been made on the machineside to ensure patient safety. In addition, the safetymeasures on these machines are built-in and hardto override; anesthesiologists have no choice of


whether to implement these measures them ornot. Conversely, there is almost nothing forcinganesthesiologists to follow best practice recommen-dations for medication safety. It requires a consciouschoice and effort. Bar code scanning is likely the besttechnological advance, other than prefilled syrin-ges, on the medication side to improve patientsafety, yet very few institutions have implementedbar code systems in the OR.

Other advances on the medication side includenetworked surveillance, which strengthens the con-nections between the anesthesiologist in the OR, thepharmacist, and the EMR to introduce more safetychecks into the flow of anesthesia medications.

To prevent wrong route administration, theInternational Standards Organization developedISO80369 in 2008 to mandate the design of smallbore connectors unique to each administrationroute.

Table 2. Expert Consensus on Recommendations for Medication Safety in the Operating Room

Culture � Incident reporting (non-punitive, analysis, interventions)� Culture of respect and collaboration� Adequate training and supervision

Pharmacy Care taken to avoid purchase of look-alike medications� Pharmacist assigned to the OR, available 24/7, provides education� Pharmacy responsible for entire medication flow� Use of compounded, prefilled or diluted medications� Unique solutions stored separately

Patient Information � Medication reconciliation� Single record� Time out (patient, weight, allergies)� Automated alerts (dose, allergy, med-med interactions)� Establish weight-based limits (smart pumps, paper chart)

Medication information � Systems allow user to quickly pull up information about medications or ask a pharmacist� Cognitive aids, rescue protocols, infusion rate charts� Specialized carts with protocols

Cart inventory � Drug trays (standardized across locations, organized, labeled divisions, pharmacy manages)� Eliminate unusual drugs (unique tray, remove at end of case)� Single-use vials, if multi-use, remove at end of case� High-risk, dangerous medications (no concentrated medications, only one concentration of infusions,

pharmacy dilutes, alert label on high-risk meds)� Separate regional cart (regional anesthetics sequestered, only preservative-free regional meds)� Pharmacy prepares all compounded drugs

Medication administration � Every medication labeled always (name, concentration, date, preprinted, color coded, bar code)� Avoid abbreviations and trailing zeros� Immediately discard unlabeled syringes� Minimize provider prepared medications (prefilled, compounded, diluted by pharmacy, 2-person check

of very high-risk and weight based)� Bar code scanning� Aseptic technique (cap syringes, sterile technique)� Read and verify every vial, ampoule, syringe (bar code, 2-person check)� Smart pumps (standardized, guard rails, alerts)� Identify route of administration

Teamwork � Communication (speak-back, closed loop, using agreed upon numerical/alphabetical conventions,medication review at every handoff

� Utilize team in high-risk medication administration� Practice a questioning attitude� Validate and verify

This is extracted from Prof Wahr’s slide.


Finally, Professor Wahr concluded by a newthinking about safety. For much of the last 20 years,we have been focused on what goes wrong. Thisapproach is necessary and cannot ever go away.But it is also necessary to focus on what goes rightin order to inform, prevent wrong actions and there-fore get safer.

References

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Eichhorn JH. APSF Newsletter. 2010;25(1):1-20. https://www.apsf.org/wp-content/uploads/newsletters/2010/spring/pdf/APSF201006.pdf Accessed August 2, 2019.

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Grigg EB, Roesler A. Anesthesia medication handlingneeds a new vision. Anesth Analg. 2018;126(1):346-350.
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Jensen LS, Merry AF, Webster CS, Weller J, Larsson L.Evidence-based strategies for preventing drug adminis-tration errors during anaesthesia. Anaesthesia. 2004;59(5):493-504.

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Merry AF, Hannam JA, Webster CS, Edwards KE, TorrieJ, Frampton C, Wheeler DW, Gupta AK, Mahajan RP,Evley R, Weller JM. Retesting the Hypothesis of aClinical Randomized Controlled Trial in a SimulationEnvironment to Validate Anesthesia Simulation inError Research (the VASER Study). Anesthesiology.2017; 126(3):472-481.

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Merry AF, Webster CS, Hannam J, Mitchell SJ, Hen-derson R, Reid P, Edwards KE, Jardim A, Pak N,Cooper J, Hopley L, Frampton C, Short TG. Multi-modal system designed to reduce errors in recordingand administration of drugs in anaesthesia: prospec-tive randomised clinical evaluation. BMJ. 2011;343:d5543.
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Wahr, J. A., et al. (2017). ‘‘Medication safety in theoperating room: literature and expert-based recom-mendations.’’ British journal of anaesthesia 118(1):32-43.

https://www.apsf.org/wp-content/uploads/newsletters/2010/spring/pdf/APSF201006.pdf




SYMPOSIUM CONCLUSIONAnesthesiologists are the patient safety advocatesin the OR, and are positioned to recognize pro-cesses and factors that increase the risk of medica-tion errors and take the initiative to implementchanges at their institutions to reduce that risk.Technological advances, such as bar code systems,can prevent errors despite human factors but at a


high cost, whereas other interventions—cart orga-nization, assigning a pharmacist to the OR, orfostering a culture of teamwork in the OR—maycost less but require a change in practice andconscious effort by the OR team. Anesthesiologistscould also engage manufacturers to find new sol-utions to reduce medication errors and improvepatient safety.

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