O C T O B E R 2 0 1 5 O U T P A T I E N TS U R G E R Y. N E T 3 5
not be able to completely prevent
medication mishaps from occurring,
but you can put systems in place to
ensure errors don't result in patient
harm.
Learn and improve
There are 2 ways to approach medica-
tion safety improvement. The first is a
"person approach," in which you look
at medication errors as occurring due
to human imperfections: forgetfulness,
poor motivation, carelessness, inatten-
tion or even negligence. Solutions from
this perspective include disciplinary
actions and blaming individuals. The
second and superior approach is a
"systems-based approach." Errors are
viewed as the end result of imperfect
systems.
Even the best systems fail. It's up to
you to devise solutions based on
changing conditions,
instead of focus-
ing on changing humans. How?
Implement barriers and safeguards to
help prevent errors. When errors do
occur, assess how and why the system
failed instead of focusing on which
individual erred.
Anesthesia providers and nurses
administer most medications. When
errors occur, ask representative lead-
ers of both groups to meet as a quality
improvement committee to assess the
conditions that made the error possi-
ble and to work together to eliminate
these conditions.
Was the error due to look-alike,
sound-alike (LASA) medications?
For example, if an anesthesia
Safety
z READ THE LABEL Medications that reach the
sterile field must be clearly and properly marked.
