Tools to Improve Medication Safety

To eliminate administration mistakes, you have to eliminate the human factor.

Ronald Litman, DO, ML -BIO | EMAIL Category: Outpatient Surgery > General Anesthesia

HUMAN ERROR Well-intentioned surgical team members check and recheck labels, but medication administration mistakes can still occur.

Only in the OR can you prescribe, prepare and administer medications with no input from a second provider and no electronic clinical-decision support — and often under stressful or chaotic conditions. What could possibly go wrong?

You guessed it: plenty. Surgical teams administer the right medication to the right patient at the right time most of the time, but when things go wrong, as they inevitably do, the consequences can be cataclysmic. I once investigated a case in which an 11-year-old boy died because his anesthesiologist meant to give him ondansetron, but accidentally gave him phenylephrine, a blood pressure-boosting drug, because the similar-looking vials were next to each other in the anesthesia drug tray. Not only was it the wrong drug, but phenylephrine is so concentrated that it requires a 100-fold dilution. The mistake caused the child to have severe hypertension and a pulmonary hemorrhage. His young life ended the next day.

You need to eliminate the human factor in order to prevent such a devastating mistake from happening on your watch. Unfortunately, that's easier said than done.

Slip-ups and solutions

When we think about our typical procedures in the OR, it's easy to see that we're asking for trouble. Consider the traditional old-fashioned way of drawing up medications. If I need something, say morphine, it's sitting in a drawer. If I plan to give it to my patient, I take an empty syringe and needle and draw it out. Then I label it. Then I put it on my anesthesia table, and when I want to give it to the patient, I reach for it.It sounds really simple, but it's not. The reason: I'm human and one day, inevitably, I'll make a mistake. I'll pick up the wrong ampoule. One that looks like morphine, but isn't. Even if I choose the right drug, there's still a chance I'll put the wrong label on the syringe. Why? I'm human, and humans make mistakes.

Or, let's say I manage to get the right drug in the syringe, and accurately label it. It says morphine, and it is morphine. Unfortunately, I'm still not out of the woods. What's to prevent me from accidentally picking up the wrong syringe, and falling prey to what's known as syringe swap?

So what can you do to protect patients from imperfect staff? Here are a few ways to take the human element out of medication administration in the OR:

1. Label making. One solution is to equip each OR with a machine that automatically prints labels when the anesthesia provider scans the barcodes on the ampoules. That's certainly a good option, although it's not ideal for a few reasons. One is that you have to buy a machine for each OR, and they aren't cheap. Another is that it still doesn't prevent you from putting the wrong medication in your syringe. All it does is put an accurate label on the syringe, which you may or may not notice.  But most concerning is that its efficacy is dependent on the willingness of providers to use the thing. There isn't a lot of research on this, but a study in which anesthesiologists were encouraged to use a label-printing machine found that only about 40% followed through and did so. The researchers even tried upping the ante. They said every day you use it we'll give you a free coffee card. That bumped usage up to about 70%. Even with the enticement of a free caramel macchiato, roughly a third of the providers in the study found the process too cumbersome to fully embrace.  

2. Color-coded labels. This is another safeguard that could help ensure the right medication reaches the patient on the sterile field. We know that all opioid labels are blue, all paralytic labels are reddish orange and all anesthetic labels are yellow.  There are two potential ways color-coded safety labels are effective. One is that the drugs are easier to recognize. That's fine. But the more important theory is that if you accidentally give someone the wrong drug, at least you'll be giving one that's in the same class. The thinking being that it's not likely to be as big of a deal if I give someone fentanyl instead of morphine, as it would be if I accidentally gave him a paralytic.

3. Prefilled syringes. Whether they come directly from the manufacturer, from a third-party distributor, or from your hospital pharmacy, prefilled syringes are a great start toward solving the problem, because they eliminate a whole category of mistakes. They banish ampoule swaps, those cases where you fill your syringe with the wrong drug, because they eliminate the need for ampoules.

They also offer several other advantages. By essentially eliminating the need for needle syringes, they can eliminate accidental needle sticks and prevent certain unsafe injection practices, like reusing syringes. They're more expensive, but they can save money by decreasing wastage and by maintaining their sterility longer than other preparations.

4. Barcode scanning. To prevent syringe swap, you also need other, more sophisticated solutions. The only way to be sure you won't pick up the wrong syringe is to build in some kind of engineering system that prevents you from doing so, such as mandatory barcode scanning before drug administration. EHRs that require you to scan the barcode on the syringe label before you can enter the information help prevent syringe swap. You can't just mindlessly pick up a syringe. You have to stop, and look at its label. And what you enter has to match what pops up on the computer. There's an added benefit to such a system, because you can also program in alerts. If, for example, you're about to give a patient morphine, but the patient is allergic to morphine, the system can warn you.

Nothing is fail-safe, but the best way to lower the risk of medication errors in the OR is to have prefilled, prelabeled syringes that must be scanned before they're used.

Unfortunately, none of those things will actually prevent someone from administering the wrong drug. Providers need to acknowledge and openly address the fact that vigilance-based care is limited by human frailties. In other words, engineering solutions and technological assistance are the only ways to prevent medication errors. OSM

medication labeling, medication safety

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