3 6 S U P P L E M E N T T O O U T P A T I E N T S U R G E R Y M A G A Z I N E O C T O B E R 2 0 1 5
provider administers a dose of undi-
luted intravenous phenylephrine
when he intended to administer a
dose of intravenous atropine, a sys-
tems approach may reveal that the 2
ampoules looked alike and were
stored in adjacent locations in the
anesthesia drug drawer. A quality improvement would include changing the
vendor for one of the medications, so that the ampoules do not look similar,
or moving the undiluted phenylephrine ampoules to a drug locker removed
from the operating room to reduce the likelihood of a mistaken administra-
tion.
A specific challenge to the surgical arena is that anesthesia providers both
choose and administer medications without input from a second healthcare pro-
fessional. An anesthesia provider administers multiple potentially harmful med-
ications to patients every day, medications he chooses without an order and
without checks or balances. He can draw up a wrong ampoule, label a syringe
incorrectly or administer a drug from the wrong syringe with minimal interfer-
ence from other professionals. This makes a systems approach to eliminating
anesthesia provider errors more difficult to set up.
Labels leave no doubt
Ensure each drug label on each syringe or container that reaches the sterile
field notes the drug, strength, date, time drawn and the drawer's initials.
Although best practice is to note the expiration date on ampoules as well, busy
anesthesia providers rarely check this on the dozens of ampoules they handle
each day. They trust that the facility's staff regularly screens drug supplies and
eliminates expired ampoules. This makes the management and monitoring of
your medication inventory critically important.
Use "Tall Man Lettering" to highlight distinctive syllables in similar looking
z EASY ON THE EYE Color-coded
labels reduce risk of medication mix-ups.
Pamela
Bevelhymer,
RN,
BSN
