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Prevention of perioperative medication errors

Prevention of perioperative medication errors
Literature review current through: Jan 2024.
This topic last updated: Mar 07, 2023.

INTRODUCTION — A medication error is any mistake in the intended use of a medication (eg, wrong medication, wrong dose, or infusion of the wrong medication into the wrong place). The perioperative period is a high-risk setting for such errors [1-6].

This topic focuses on prevention of medication errors in the perioperative setting. Recommendations to prevent such errors and other adverse medication events in other areas of the hospital (eg, inpatient wards, intensive care units, emergency department) and after hospital discharge are discussed in a separate topic. (See "Prevention of adverse drug events in hospitals".)

GENERAL CONSIDERATIONS

Perioperative processes for medication use — Medication use includes the following processes [1,2,7,8]:

Medication selection or ordering

Dispensing

Preparing

Administering

Documenting

Monitoring, if applicable (eg, checking glucose levels after insulin administration)

An uncorrected mistake in any of these processes (that has the potential for patient harm) results in a medication error.

The intraoperative setting is unique because a single anesthesia clinician performs all of these tasks [9]. Typically, there is no routine point at which a mandated double-check occurs (with either a second person or a computer/barcode) for either the selected vial or syringe containing the medication or for the administered dose.

Types and incidence of errors

Intravenous medication errors

Types of errors – In a prospective observational study of 3,671 intraoperative medication administrations, the most common types of intravenous (IV) medication errors were incorrect dosing, medication labeling error, and failure to act [2]. Failure to act is an error of omission, in that the intended medication is not administered (eg, failure to administer perioperative antibiotics, or re-dose an antibiotic when indicated) [10,11]. Incorrect dose was the most frequent medication error associated with significant harm resulting in a lawsuit in the American Society of Anesthesiologists (ASA) Closed Claims Project database, while a syringe or ampule swap was the second-most common error [12]. Incorrect dose has also been the most frequently reported error type in pediatric patients, while incorrect medication, including syringe swap, was the second-most common error [13-15]. Even among experienced anesthesiology personnel, medication calculation errors are common [16].

Another example is the challenges inherent in mixing medications into a single syringe (eg, pharmaceutical incompatibilities or different pharmacokinetic behavior of the mixed agents [17]. Clinicians should be aware of potential physical incompatibilities of the various medications they use. For example, sugammadex precipitates when administered together with labetalol, dobutamine, amiodarone, or protamine [18,19]. Thus, intravenous (IV) lines must be adequately flushed between administration of bolus doses of an agent, and a separate IV line is necessary for continuous infusion of medications that are incompatible with other agents.

Types of medications – Medications commonly involved in errors are opioids; sedative-hypnotics, such as propofol; antibiotics; and vasoactive agents such as phenylephrine [2,13,14]. Also, 9 percent of closed claim lawsuits involved muscle relaxants administered to an awake patient that resulted in awareness [12].

Risk factors – Absence of a medication label or improper medication labeling is the most frequently cited risk for perioperative medication error [2,20]. Duration of procedure has been associated with an increased incidence of medication errors [2,13]. However, procedure type, provider type (resident, nurse anesthetist, attending anesthesiologist), ASA physical status score (table 1), patient age, and body mass index (BMI) have not been associated with risk of error [2].

Incidence – Observational studies in the operating room (OR) report medication error rates between 4 to 11 percent of all medications administered [2,10], similar to reports of medication error rates for inpatient hospital settings (5 to 15 percent) [21-23], critical care settings (9 to 20 percent) [24,25], and outpatient settings (7 to 12 percent) [26-28]. Most errors in these other settings are due to prescribing errors (as ordered by the clinician), administration errors (as given by the nurse), or dispensing errors (as dispensed by the pharmacist).

Wrong route errors — Infusion of a medication or gas using the wrong route can also occur, and these errors are particularly likely to cause patient harm (see 'Errors resulting in adverse medication events' below). Wrong route errors occur because catheters are placed in various body sites (eg, IV, intrathecal, intra-arterial, gastrointestinal), and the Luer connection is ubiquitous. It is possible to accidentally administer IV medications or solutions into the intrathecal space with potentially devastating consequences, or vice versa [14,29,30]. In one review of neuraxial versus intravenous misconnection covering a 20-year period, 133 case studies and 42 unique drugs were found, with the most commonly reported events involved administration of an epidural medication via an intravenous catheter (29.2 percent of events) or administration of an intravenous medication via an epidural catheter (27.7 percent) [31]. Outcomes were directly related to the toxicity of the drug that was unintentionally administered. Patient deaths were reported due to the erroneous administration of chemotherapies (n=16), muscle relaxants (n=4), local anesthetics (n=4), opioids (n=1), and antifibrinolytics (n=1). Severe outcomes, including paraplegia, paraparesis, spinal cord injury, and seizures were reported with the following medications: vincristine, gadolinium, diatrizoate meglumine, doxorubicin, mercurochrome, paracetamol, and potassium chloride [31]. Several other reports have noted that administration of intrathecal tranexamic acid has a high incidence of mortality (approximately 50 percent), and survivors may have permanent neurologic injury including paraplegia, seizures, or ventricular fibrillation [32-34].

Other examples of wrong route errors include enteral feeds that have been infused IV, into the intrathecal space, and into hemodialysis ports [35], or priming of pressure transducers with a medication-containing solution [14].

Errors resulting in adverse medication events — An adverse medication event is patient harm or injury due to a clinical intervention related to a specific medication, regardless of whether any errors in selection or processing of the medication occurred. An example of an adverse medication event due to error is a patient with a known medication allergy who receives that medication and develops a reaction. An example of an adverse medication event with no error is a patient with no known allergies who receives a new medication and develops a first-time allergic reaction.

A medication error may or may not involve an adverse event (figure 1). For example, forgetting to administer a perioperative antibiotic may or may not lead to a postoperative patient infection. Cases where the error does not lead to patient harm are termed "near-misses" or errors with a potential adverse medication event.

In a review of 172 fatal iatrogenic and in-hospital medication errors, the most commonly reported type of error was "incorrect dose," (22.7 percent) [36]. The most common route of exposure was intravenous (54.9 percent), followed by ingestion (30.2 percent), then intrathecal (7.0 percent). The most common medications were cardiac drugs, opioids, sedative-hypnotics, anticoagulants, and chemotherapeutic agents [36].

Detection of errors — The commonly used methods for detecting medication errors and adverse medication events include self-reporting, incident reporting, manual chart review, automated computerized surveillance, and direct observation. (See "Prevention of adverse drug events in hospitals", section on 'Detection methods'.)

Self-reporting

Voluntary self-reporting – Self-reporting systems rely on those involved in an event to initiate an event report that provides detailed information. Such self-reporting may be confidential (identity of the reporter is known but legal protection is provided) or anonymous (reporter cannot be identified and follow-up may be more difficult).

Numerous national anesthesia-incident reporting systems exist, including ones in the United States, Australia/New Zealand, Switzerland, and Germany, and are being instituted in many more countries.

Although valuable to highlight rare but lethal or high-harm events, self-reporting is subject to underreporting and recall bias. Compared with chart review and direct observation, self-reporting only captures a fraction of events and may not reliably identify serious events [2,37,38]. Also, self-reporting provides the numerator (number of errors occurring), but not the denominator (number of events vulnerable to such an error), and a medication error rate cannot be determined.

Facilitated self-reporting – Facilitated self-reporting systems prompt providers to report safety events after every anesthetic, even if there were no incidents [13,39]. These reports provide a numerator for identified errors, as well as a denominator (number of anesthetics included in the facilitated reporting system), thereby allowing calculation of the error rate per anesthetic. Limitations include inability to capture errors that were not recognized by the provider (eg, omission of antibiotic redosing, failure to appreciate and treat hypotension).

Mandatory incident reporting – Mandatory event reporting systems are typically enacted under state law and require health care facilities to report errors resulting in serious patient harm or death (eg, Pennsylvania mandatory event reporting, Massachusetts mandatory event reporting). Systems for mandatory incident reporting are also subject to underreporting [40], cannot determine an error rate, and frequently do not include critical information to identify the cause of an error or guide development of prevention strategies.

Chart review and computerized surveillance – Chart reviews are based on predefined criteria (ie, "red-flags"). Examples in an OR environment are discrepancies in medication counts at the end of a case, use of certain medications (eg, naloxone, insulin, dextrose 50 percent solution), or findings of abnormal laboratory test results (eg, high or low postoperative glucose level) [38]. Automated computerized surveillance of records may detect many such examples.

Chart reviews and computerized surveillance are useful to detect and investigate medication errors in settings outside the OR because a clinician's medication orders specifying the intended medication and dose can be compared with nursing medication administration records [38,41]. These methods are less useful in the OR as there are no written or electronic orders that can be verified against a medication administration record. (See 'Perioperative processes for medication use' above.)

Direct observation – Direct observation utilizes a trained individual to observe medication process in the OR, using a predefined checklist of potential errors [1,2,10]. The clinical significance of errors is assessed by an adjudication committee to determine the likelihood and severity of potential adverse medication events [42], based on patient and procedural context that may be missed by the observer [2,11]. This method is resource-intensive but is more sensitive than self-reporting, mandatory incident reporting, or chart review [38,42]. (See "Prevention of adverse drug events in hospitals", section on 'Detection methods'.)

PREOPERATIVE MEDICATION RECONCILIATION — An important preoperative step to avoid medication errors is medication reconciliation (verification of which medications are prescribed and whether the patient is taking each of these appropriately) [43]. (See "Prevention of adverse drug events in hospitals", section on 'Medication reconciliation'.)

Although not limited to operating room settings, a 2021 systematic review noted that medication reconciliation was the most common type of intervention studied in hospitals, resulting in likely reductions in adverse drug events (odds ratio [OR] 0.38, 95% CI 0.18-0.80; three studies, 1336 participants), and possible reductions in medication errors (OR 0.55, 95% CI 0.17-1.74; three studies, 379 participants) compared with no medication reconciliation [44]. In particular, multimodal medication reconciliation interventions increased discrepancy resolutions compared with usual care (relative risk [RR] 2.14, 95% CI 1.81-2.53; one study, 487 participants).

Notably, accurate medication reconciliation can be difficult and time consuming (45 to 90 minutes) [45,46]. One study noted that 25 percent of high-risk inpatients had at least one medication error associated with poor medication reconciliation during hospital admission. The most common errors were omissions of chronically administered medications [47]. Even when a medication list is accurate, outpatient medications are typically replaced by inpatient medications, a process that may generate errors. Another study noted failure to continue an appropriate home medication in 50 percent of inpatients and administration of an incorrect dose in 20 percent [48]. In a study of patients undergoing spinal surgery, 73 medication reconciliation errors were found in 149 patients, resulting in 36 percent of these patients not receiving correct doses of at least one medication while in the hospital [49].

In the perioperative setting, professional society guidelines for managing preoperative administration of certain medications may change or be updated (eg, anticoagulants, angiotensin-converting enzyme [ACE] inhibitors, beta blockers) (see "Perioperative medication management"). Clinician responsibility for perioperative medication reconciliation may shift among the patient's primary care doctor, surgeon, and preoperative anesthesia care team members, which can be confusing if communication regarding medications is not consistent. For this reason, patients should receive clear written instructions if medications are to be withheld preoperatively or if any substitutions are made. Even with such instructions, patient-related errors are not uncommon (eg, incorrect times for discontinuation of a medication). For example, in one study, failure to discontinue anticoagulants resulted in case cancellation in 19 percent of patients receiving those agents [49]. Thus, a second medication reconciliation is necessary in the immediate preoperative period [43].

STRATEGIES TO PREVENT INTRAOPERATIVE MEDICATION ERRORS

General concepts — Medication use in the perioperative setting presents particular patient safety challenges because it usually bypasses standard safety checks, such as computerized physician order entry (CPOE) with clinical decision support, pharmacy approval of medications, and redundant nursing checks prior to medication administration (see "Prevention of adverse drug events in hospitals"). As noted above, the operating room (OR) is the only setting within the hospital where a single clinician is responsible for medication selection, dispensing, preparing/diluting, administering, documenting, and monitoring after a medication is given [9] (see 'Perioperative processes for medication use' above). The absence of electronic or multiple-provider double checks during the complex perioperative medication use process may contribute to errors. Also, rapid changes in intraoperative patient condition often create a need for unanticipated administration of several medications in a brief period of time. For these reasons, medication errors are the most frequently cited critical incidents in anesthetic care [50], including syringe or ampule swaps and wrong dose errors that can cause serious harm [51].

The Anesthesia Patient Safety Foundation (APSF) in the United States, as well as the Association of Anaesthetists, the Society for Intravenous Anaesthesia, and the Safe Anaesthesia Liaison Group (SALG) in the United Kingdom, the Australian and New Zealand College of Anaesthetists (ANZCA), and international groups such as the EZDrugID global initiative and the International Society of Pharmacovigilance (ISoP) have each recommended prevention strategies for perioperative medication errors [52-56]. These are based on standardization, as well as elimination of look-alike medication vials and labels, pharmacy solutions, technology solutions, and improvements in institutional culture. These strategies are supported by expert opinion, although there are few data regarding interventions to prevent anesthesia-related medication errors [57-59].

There have been only two randomized controlled trials to test potential interventions. In the first, Merry and his colleagues showed that their multifaceted medication safety system, which involves medication barcode scanning, computerized visual and auditory read-back of medication names, and a standardized medication cart organization, reduced medication error rates from 11 to 9 percent of medication administrations [10]. The second randomized controlled study was conducted to test the results of this first study in a simulation setting. In the simulation setting, the authors found a greater reduction of error rates (from 11 to 6 percent) using their medication safety system than in the real-world setting (11 to 9 percent) [60].

Standardization — Multiple strategies have been developed for standardization to reduce drug errors.

Standardized labels — Errors in medication labeling are the most frequently cited type of perioperative medication error [2,20]. Syringes and infusions should have standardized labels. The Joint Commission requires labeling of all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings in hospital and ambulatory centers.

Labels on all syringes, solutions for infusion, and open containers on the sterile surgical field should include the following information [61]:

Medication or solution name, strength, and amount of medication (if not apparent from markings on the syringe)

Diluent name and volume (if not apparent from the markings on the syringe)

Expiration date when not used within 24 hours [62]

Expiration time when expiration occurs in less than 24 hours

Medications must be labeled immediately after preparation (unless they are immediately administered by the clinician preparing the syringe, without any break in the process) [63]. Each vial label and syringe label must be carefully read by the clinician prior to each use.

The layout of syringes in the anesthesia medication tray and workspace is also standardized, and any unlabeled syringes are promptly discarded at the end of each case. (See 'Standardized medication trays and storage' below.)

Tallman lettering — Medication errors may be reduced by highlighting the portion of a medication name most likely to cause confusion [64,65]. Lower case Tallman lettering is a standardized method to distinguish the dissimilar portions of easily confused medication names [66]. Most preprinted labels for syringes and solutions for infusion incorporate this technology.

Color-coded labels — The American Society for Testing and Material (ASTM) has created a standard for color-coding user-applied medication labels for different classes of medications in the OR (ASTM D4774-06 Standard Specification for User Applied Drug Labels in Anesthesiology) [67]. Labels are blue for opioids, fluorescent red for neuromuscular blockers, yellow for induction agents, orange for tranquilizers, violet for vasopressors, and green for anticholinergics. Used as a supplemental tool for labeling, rather than as a substitute for clear lettering, this tool is particularly useful to prevent accidental swaps between medication classes [8,68]. Even in low-resource settings, color-coded ribbon labels can be employed at very low cost, and are an easy, durable, and effective to prevent medication administration errors (picture 1) [69]. Color-coding does not prevent errors within a medication class, but such swaps are generally less likely to cause serious harm than between-class errors [8,70]. However, medications prepared in the OR pharmacy may not utilize color-coding, so vigilance is necessary before administration of any plain white-labeled medication.

For medical gas cylinders, there is an international color-coding system that differs from colors used in the United States. For example, the international standard color is white for an oxygen tank (green in the United States) and black and white for an air tank (yellow in the United States). The international color for suction tubing is yellow (white in the United States) [8]. Such international discrepancies in color-coding are a potential source of error.

Barcode-assisted syringe labeling — Commercially available barcode-assisted syringe-labeling technologies have been developed to improve compliance with the labeling requirements mandated by the Joint Commission [71]. There is limited evidence linking these technologies to reduction in medication errors without the concurrent use of point-of-care barcode-assisted medication administration with clinical decision support [10,44].

Standardized concentrations of high-alert medications — Ideally, high-alert medications are available in only one to two concentrations within an institution (one if adult only, two if adult and pediatric, possibly three for neonates), and such medications are prepared by the hospital pharmacy or a third party to be available in a ready-to-use form that is appropriate for both adult and pediatric patients [53,59].

In some institutions, a two-person check is also used prior to administration of a high-risk concentrated medication (eg, insulin).

Standardized medication trays and storage — We agree with expert consensus that medication trays in anesthesia carts should be standardized across all locations within an institution, with drugs clearly labeled and positioned logically to minimize confusion (eg, organized by medication class, compartmentalized, color-coded) [10,59,72].

Strategies to reduce medication errors include storing uncommonly used medications such as insulin or protamine in a separate color-coded bin or cart rather than the standard workspace, and a process for clearing these medications out of an OR after each case to avoid inadvertent administration in a subsequent case [10]. Also, uncommonly used solutions (eg, hypertonic saline, dextran) should not be stored in the standard workspace [59,73]. Local anesthetics for regional nerve blocks or neuraxial blocks should be stored only in unique block carts and should not be available in a medication tray.

Standardized handoffs — A standardized process should exist for confirming medications and allergies during intraoperative and postoperative handoffs. A poor handoff process coupled with a documentation error can be particularly dangerous. For example, if a medication was not documented in the AIMS and not reviewed during the handoff, it may be re-administered after the handoff, resulting in an overdose. All medications should be reviewed during intraoperative care handoffs between anesthesia clinicians, and postoperative handoffs in the post-anesthesia care recovery unit or intensive care unit.

Technology solutions

Clinical decision support — CPOE systems are common on hospital wards and outpatient clinics where providers receive helpful information and/or alerts electronically based on each medication order they write. More errors are prevented when clinical decision support tools are fully implemented and meaningfully used (without bypassing critical functionality), typically after adequate training, support, and familiarity over time [74-76]. (See "Prevention of adverse drug events in hospitals", section on 'Computerized physician order entry'.)

However, CPOE is not typically used in OR settings due to unique medication administration processes and rapid changes in patient condition. This absence of clinical decision support and alerts for drug-drug interactions or allergies may lead to higher frequency and severity of medication errors. Development of clinical decision support systems that integrate intraoperative medication administration, real-time vital signs, and the patient's electronic medical record would support both workflow efficiency and decision-making in real time for anesthesia providers [77]. (See "Prevention of adverse drug events in hospitals", section on 'Electronic medication administration record'.) Key elements of the 2022 Institute for Safe Medication Practices (ISMP) guidelines for safe medication use in perioperative and procedural settings included point-of-care medication checks, with clinical decision support facilitated by barcode scanning technology [78,79]. In one randomized trial, a novel perioperative clinical decision support software platform outperformed standard medication use workflow by improving efficiency (saving 20 percent of time spent on medication documentation) and quality of care metrics, including tighter blood pressure control and more accurate dosing adjustments for patients with organ dysfunction [80].

Alerts are typically used in conjunction with clinical decision support systems in both inpatient and outpatient settings, with safeguards to prevent inappropriate overriding [81-84]. However, only limited alerts are routinely available in the OR setting. These include:

Soft alerts incorporated within automated medication dispensing systems (eg, reminder of the need for dilution of vasoactive agents).

Barcode-assisted medication administration alerts (eg, reminder of an individual patient allergy).

Medication infusion 'smart' pumps — Medication infusion "smart" pumps have the potential to detect and prevent serious errors. However, their utility depends primarily on the operator's use of the medication library incorporated in the pump and acceptance of the suggested dosing limits, rather than relying on manual programming [15,85]. (See "Intravenous infusion devices for perioperative use" and "Prevention of adverse drug events in hospitals", section on 'Smart pumps'.)

The APSF recommends use of medication infusion pumps containing a medication library standardized within an institution for high-alert medications such as vasoactive agents [53]. If such infusion pumps are connected to an anesthesia information management system, then documentation of the infusion rate and medication dose can be automatically performed [8]. (See 'Clinical decision support' above and "Prevention of adverse drug events in hospitals", section on 'Electronic medication administration record'.)

Barcode-assisted medication administration — Barcodes are a point-of-care system requiring positive patient identification and electronic verification of medications at the bedside prior to administration [86-88]. Although not limited to operating room settings, a 2021 systematic review noted that barcode identification of the patient and medications may reduce mediation errors (odds ratio [OR] 0.69, 95% CI 0.59-0.79; two studies, 50,545 participants) [44]. (See "Prevention of adverse drug events in hospitals", section on 'Bar coding'.)

In the OR, barcode assistance occurs during two phases [8,71]:

Medication preparation when the clinician scans a vial and the system generates a barcoded label before preparation of the medication in a syringe or infusion bag.

Medication administration when the clinician scans the barcoded label immediately before administration.

Barcode-assisted medication administration systems developed for perioperative use provide both visual display and auditory alerts regarding the selected medication and concentration [8,71]. Such systems aid with accurate documentation and can be linked to use of electronic audits and feedback [89], as well as clinical decision support systems [10,87]. (See 'Clinical decision support' above and "Prevention of adverse drug events in hospitals", section on 'Electronic medication administration record'.)

Automated software tracking of controlled substances — Controlled substance management errors, discrepancies, and potential for diversion were reduced after integration of a software application into the electronic health record (EHR) and pharmacy systems in a large observational study that included >50,000 cases before and >50,000 cases after implementation of the controlled substances management application [90].

Solutions for wrong route errors — The International Standards Organization standard 80369 requires unique connector devices for access to each body site to reduce medication route errors [91-93]. For example, unique connectors have been designed for enteral feeding tubes (EnFIT) and for neuraxial and regional analgesia systems (NRFIT). EnFit systems are being implemented widely; NRFit is available but not widely used to date.

Despite unique connectors, health care workers can devise work-arounds that result in a misconnection. Thus, anesthesia providers should clearly label all infusion lines and each point of entry in the line (stopcock, infusion hub) with the intended site of administration. Stopcocks should not be included at any point in a neuraxial infusion line. Color coding of the labels has been proposed for each site (eg, red for intra-arterial, blue for intravenous, yellow for intrathecal, green for gastrointestinal); however, there are no data demonstrating error reduction with such labels [59].

Pharmacy solutions

Prefilled syringes — Prefilled syringes are ideally prepared either by the hospital pharmacy or a third party with a standardized and accurate medication dilution and a standardized label [15], reducing opportunities for error with vial selection, transfer to syringe, and syringe labeling While cost for prefilled syringes is typically higher than medication vials [71], they may reduce dosing errors and waste, and may also improve work efficiency [94-96]. However, use of prefilled syringes and barcode-assisted technology does not eliminate all medication errors [97,98].

Since eliminating most concentrated forms of high-alert medications from the anesthesia cart has become standard practice, some institutions use prefilled syringes only for high-risk medications, such as succinylcholine and phenylephrine, in order to save costs. (See "Prevention of adverse drug events in hospitals", section on 'High-risk drugs'.)

Premixed solutions — Similar to prefilled syringes, the hospital pharmacy or a third party can provide diluted high-risk medications (eg, insulin, heparin, vasopressors, vasodilators) in standard concentrations [59]. Premixed solutions should be available in standard concentrations across units, and only one concentration should be available in all anesthesia carts within an institution, although may differ between adults and pediatrics (especially neonates) [15,59]. Potentially lethal medications, such as IV potassium, should not be available in concentrated form [59].

Avoid look-alike medications — Avoid look-alike medications during the pharmacy ordering or preparation processes. For example, if two medication vials are similar in appearance, providing one of them in prefilled syringe format can prevent errors [8,55,56].

Avoid multiuse vials — Eliminating most multidose vials from the anesthesia cart or discarding opened multidose vials at the end of a case has become standard practice in most institutions [59,62]. While certain medication vials may be designated as multiuse or multidose by the manufacturer, using a vial of medication multiple times can lead to problems, even if used in the same patient or on the same day. Hazards associated with this practice include failing to properly disinfect rubber stoppers, failing to ensure use of new needles and syringes for every step, injecting air into the vial before removal of the medication, reinjecting small amounts of medication back into the vial during removal of additional medication, storing medications at improper temperatures, and using vials after their expiration date [62]. There have been several high-profile instances of transmission of infectious diseases, such as hepatitis C or a bacterial infection after use of multiuse vials [99,100].

During the novel coronavirus disease 2019 (COVID-19 or nCoV) pandemic, shortages of some medications have prompted institutional approaches for exceptions to the general rule to avoid multiuse vials, in which the hospital pharmacy prepares individual patient doses. (See 'Medication management during the COVID-19 pandemic' below.)

Clinical pharmacist consultants — Pharmacy practices play an important role in preventing medication errors and adverse medication events. Selected clinical pharmacists are trained as perioperative consultants and specifically assigned to support the ORs, with availability for questions at all times [15,53,59]. These pharmacists also provide valuable participation in education including morbidity and mortality rounds. (See "Prevention of adverse drug events in hospitals", section on 'Pharmacist interventions'.)

INSTITUTIONAL APPROACHES — All hospitals should maintain a confidential event reporting system that includes [15,37]:

A supportive environment for event reporting that protects the privacy of staff who report occurrences.

Encouragement of reports from a broad range of personnel.

Structured mechanisms for timely review of reports and development action plans.

Follow-up to ensure implementation of improvements when a medication error or "near-miss" is verified.

The traditional view is that quality problems and errors are failings on the part of individual providers, reflecting inadequate knowledge or skill levels. A systems approach assumes that most errors reflect predictable human failings in the context of poorly-designed systems, such as expected lapses in human vigilance during long work hours or predictable mistakes during cognitively complex situations [52,101]. We use the systems approach to catch human errors before they occur or intercept them before they cause patient harm. (See "Prevention of adverse drug events in hospitals", section on 'System-based approach'.)

Cultural aspects of this approach include:

Establishing a just culture – A "just culture" of safety encourages reporting of medication errors in order to identify and correct vulnerabilities within the institution. Although each individual is held accountable for his actions, the environment is nonpunitive. This encourages self-reporting of medication errors, as well as near-misses and potential vulnerabilities. Team discussions of lessons learned improves medication safety [102]. (See "Patient safety in the operating room", section on 'Incident and outcome reporting with implementation of system changes'.)

Communication and teamwork – Good communication and teamwork skills can prevent medication errors. Use of closed-loop communication (ie, speak-back) by requiring the receiver to repeat the message as heard, after which the sender verifies accuracy should be solicited prior to administering high-alert medications, such as heparin, protamine, and oxytocin [43]. (See "Patient safety in the operating room", section on 'Communication-based errors' and "Patient safety in the operating room", section on 'Team and simulation training'.)

Appropriate feedback Although not limited to operating room settings, a 2021 systematic review noted that feedback after prescribing errors may reduce medications errors (odds ratio [OR] 0.47, 95% CI 0.33-0.67; four studies, 384 participants) [44].

MEDICATION MANAGEMENT DURING THE COVID-19 PANDEMIC — During the novel coronavirus disease 2019 (COVID-19 or nCoV) pandemic, regional surges in critically ill patients has resulted in shortages of some medications needed for intubation and mechanical ventilation of COVID-19 patients in perioperative and intensive care settings in some institutions. In these institutions, decisions whether to discard unused and unopened medications that might be contaminated balance the need to avoid waste of medications in critically short supply. The goal is to avoid the need for use of less familiar alternative medications that may not be as effective or may have more adverse side effects, thereby introducing additional patient safety risks. Strategies to minimize waste of intraoperative medications that are in short supply include:

Avoiding discard of unused and unopened medications, especially those in short supply. After potential exposure to a patient suspected or confirmed to be COVID-19-positive, consider options for isolation and disinfection of such medications.

Using some medications beyond the manufacturer's labeled expiration date, if evidence-based stability data from primary literature supports extended dating.

If multiuse vials are the only source of a medication, considering hospital pharmacy preparation of syringes under sterile conditions for use in multiple patients [103,104]. A standardized pharmacy workflow for this process is designed to eliminate common hazards for such use of multidose vials. (See 'Avoid multiuse vials' above.)

Discussion of techniques for minimizing infectious risks to care providers and spread of the virus during anesthetic care of COVID-19-positive patients is available in a separate topic. (See "Overview of infection control during anesthetic care", section on 'Infectious agents transmitted by aerosol (eg, COVID-19)' and "Overview of infection control during anesthetic care", section on 'Prevention of contamination of anesthesia machines and equipment'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Patient safety in the operating room".)

SUMMARY AND RECOMMENDATIONS

Perioperative processes for medication use Use of medications in the perioperative setting is unique because a single anesthesiologist or other member of the anesthesia care team selects, dispenses, prepares, administers, documents, and subsequently monitors medication effects. Typically, there is no point at which a mandated double-check occurs for either the selected vial or syringe containing the medication or for the administered dose. (See 'Perioperative processes for medication use' above.)

Medication errors

Incidence and types of errors The most common types of perioperative intravenous (IV) medication errors involve wrong dose, labeling errors, and failure to act errors. Wrong dose and inadvertent syringe or vial swaps are the most likely errors to lead to significant patient harm. Wrong route errors with infusion of the wrong medication or gas into the wrong place can also occur. Observational studies demonstrate error rates between 5 to 11 percent of all medications administered. (See 'Types and incidence of errors' above.)

A medication error may or may not involve an adverse medication event (figure 1). (See 'Errors resulting in adverse medication events' above.)

Detection of errors Detection of medication errors occurs with voluntary or facilitated self-reporting, mandatory incident reporting, chart review or computerized surveillance, or direct observation, which is the most sensitive method. (See 'Detection of errors' above.)

Preoperative medication reconciliation An important preoperative step to avoid medication errors is medication reconciliation (ie, verification that medications are prescribed as intended and appropriately administered in the immediate preoperative period). (See 'Preoperative medication reconciliation' above.)

Strategies to prevent medication errors These strategies are based on technology solutions, standardization, and pharmacy solutions:

Standardization

-Standardized labels (picture 1) (see 'Standardized labels' above)

-Standardized concentrations and two-person check for high-alert medications (see 'Standardized concentrations of high-alert medications' above)

-Standardized medication trays and storage (see 'Standardized medication trays and storage' above)

-Standardized handoffs (see 'Standardized handoffs' above)

Technology solutions

-Clinical decision support, including alerts (see 'Clinical decision support' above)

-Medication infusion "smart" pumps (see 'Medication infusion 'smart' pumps' above)

-Barcode-assisted medication administration (see 'Barcode-assisted medication administration' above)

-Solutions for wrong route errors (see 'Solutions for wrong route errors' above)

Pharmacy solutions

-Prefilled syringes (see 'Prefilled syringes' above)

-Premixed solutions (see 'Premixed solutions' above)

-Avoid look-alike medications (see 'Avoid look-alike medications' above)

-Avoid multiuse vials (see 'Avoid multiuse vials' above)

-Clinical pharmacist consultants (see 'Clinical pharmacist consultants' above)

Institutional approaches All hospitals should maintain a confidential event reporting system that protects the privacy of staff who report medication errors or "near-misses," with structured mechanisms for timely review of reports and development of action plans, and follow-up to ensure implementation of improvements. (See 'Institutional approaches' above.)

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