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 7
Here's the ideal method for administering
medications on the sterile field. The circu-
lating nurse checks the label on the bottle
and correctly identifies the medication, the
volume and the concentration. She then
opens the vial and pours it into a container
on the sterile field. The surgical tech draws
the medication into a syringe and labels
the syringe by directly reading and copying the information off the vial label. This usually occurs
prior to the surgical case. The surgical tech then communicates the contents of the syringe to the
physician just before administration. That process can break down, because of these common
issues:
• Non-standardized care and resistance to checklists. At a recent lecture at Stanford
University about avoiding medical mistakes, the repeated mantra was "variation is the enemy of
good." Your surgical team must strive to standardize patient care as much as possible. This
includes the use of standard clinical practices and checklists. Medication checklists should
include meticulous details about potential patient allergies.
• Communication silos. The theory is that employees and medical professionals make
fewer errors if they work without distraction from other sources or departments. In terms of
medication safety, this focused silo approach should occur when medications are drawn up,
labeled or administered.
• Outside pressures. Data show that more errors occur if individuals are rushed or distracted.
For example, an anesthesia provider instructed to induce patients and turn over cases with great
rapidity is more apt to make a medication error caused by a syringe or ampoule swap. Production
or economic pressure should never negatively affect clinical performance.
— Rick Novak, MD
ROOT CAUSES
Why Medication Errors Happen
Pamela
Bevelhymer,
RN,
BSN
z IN GOOD HANDS
Standardized proto-
cols and uninter-
rupted focus during
critical stages of
medication handling
reduce risk of errors.
