What medication errors are most common in operating rooms? There are many potential hazards to patient safety in the OR and among the most prominent are medication safety issues. Do you know which medications pose the greatest risks? What steps can you take to minimize the risks, increase patient safety, and reduce your liability?

Many of the medications used in the OR are high-alert medications. When used in error, these drugs carry a higher risk of causing significant patient harm and some common examples are injectable opioids (e.g. fentanyl, remifentanil), vasopressors (e.g., phenylephrine, norepinephrine) and paralyzing agents (e.g. succinylcholine, rocuronium).

First, we will look at some of the most common medication errors in the operating room and why they happen. Then, we will look at steps you can take to make your patients safer and at the same time reduce facility costs and liability.

Operating room medication errors:

1. Choosing the wrong prepared syringe: This happens when multiple syringes have been drawn up and the wrong one is picked up for administration. Why does this happen? One of the most common reasons for this error to occur is the lack of appropriate labeling. Syringes that have been drawn up and are not for immediate use, should be labeled with all the required elements. Don’t ever assume the contents of a syringe based on the appearance of its contents.
2. Selecting the wrong medication: This happens when the wrong medication is picked up from the nursing or anesthesia cart. Why does this happen? There are several factors that increase the risk of this happening, but some of the common culprits are drugs in similar looking packaging, drugs with confused drug names that look-alike or sound-alike, and drugs that are commingled in storage containers.
3. Miscalculating dosing: As I discussed in a previous post about Nursing Medication Calculations, very few people enjoy medication calculations, but our patients rely on us to do them well every time. Any time a dose requires calculating, there is potential for error and there are many opportunities for mistakes. It can be something as simple as starting with the patient’s correct weight, to converting it from pounds to kilograms or decimal point errors.

How to reduce operating room medication errors:

1. Labeling medications correctly: The expectation and guidance on labeling medications is pretty consistent across the licensing and accrediting agencies, including the Centers for Medicare and Medicaid Services (CMS), Accreditation Association for Ambulatory Health Care (AAAHC), and  The Joint Commission (JC). Proper labeling of pre-drawn syringes should include the name of the drug, the concentration, the date, the time drawn up, the expiration time and the initials of the preparer. This should be done consistently for any medication that is not drawn up for immediate use.
2. Pay special attention to confused drug names and high-alert medications: These drugs carry a higher risk of causing significant patient harm and require special safeguards to reduce the risk of errors. Post the most recent list and ensure your staff is continuously educated on the contents of the list. Use warning labels for both Look-Alike-Sound-Alike and High-Alert medications. If the labels on the shelf are bent, frayed or in any way hard to read, replace them with fresh and clear versions. As always, the Institute for Safe Medication Practices (ISMP) is a great resource for obtaining a current list of  high-alert medications. For more information on how to handle these medications, read my post “Managing High-Alert/Hazardous and Look-Alike-Sound-Alike Medications in Ambulatory Care Settings”.
3. Standardize: Start with your formulary. It is always a good idea to minimize the number of drug concentrations available for use. As usual, with fewer choices, there are fewer opportunities to pick the wrong strength and it also reduces the risk encountered with calculations. Next, set up medication/anesthesia carts in a consistent manner. Make sure to keep the same format or layout in in each cart, bin, and tray.
4. Practice calculations: This is probably everyone’s least favorite solution. However, practice does make perfect. Despite the task being tedious at best, it is one that has a great return on the investment. We suggest routine practice with various scenarios. Take examples from close calls at your own facility and use them as teaching opportunities. At least annually, assess your staff on medication calculation competency. If you don’t have a competency exam, let us know…we provide one to each of our clients and update it at least annually.

To see some examples and pictures of items that lend themselves to medication errors, read my post titled Can you spot the patient safety issue? In this post I show examples of medication safety issues I routinely address in my practice. You can also see examples of safer medication management, which ultimately enhances patient safety and reduces facility liability.

There are many components to proper and safe medication management. Medications pose many challenges in the operating room, even when used properly. We encourage all facilities to have one licensed staff member as the go-to person for medication and pharmacy related issues on a day-to-day basis. Additionally, each facility should engage a pharmacy consultant who is expert in their specific type of facility or specialty to be part of their team. Safe medication management is a full-time job and your patients deserve the best. If you have questions or need expert advice, reach out to us…we’d be happy to help.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies. We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.