O C T O B E R 2 0 1 6 O U T P A T I E N TS U R G E R Y. N E T 1 5
Follow these tips to reduce the incidence of
medication errors and to keep drugs
secure from storage to administration.
• Use proper labeling. A recent study in
the journal Anesthesiology showed half of
more than 275 surgeries performed at
Massachusetts General Hospital in Boston
involved at least 1 medication error or
adverse drug event (osmag.net/wY4ENj).
The most frequently observed errors were
mistakes in labeling, most of which
involved unlabeled syringes of medication
being placed down for later use. The risk
of syringe swap is high if syringes aren't
labeled — most medications are clear liq-
uids and nearly impossible to differenti-
ate. All syringes therefore must be
labeled if they are not being used immedi-
ately after preparation. The provider who
draws medication from a vial into a
syringe is always responsible for labeling
that syringe. She should note the drug, the
drug's dose strength, date and time of
preparation and her initials. The provider
who delivers medication to the sterile field
should verbally confirm the name of the
drug and its dose with another member of
the surgical team.
• Store smartly. To avoid confusing look-
alike and sound-alike medications,
store similar drugs away from
each other in sections of drawers,
cabinets and carts, and try to limit storage
of drugs to single strengths. Use tall man
lettering on labels to differentiate the
potentially confusing parts of similar-look-
ing and -sounding medications, and affix
warning labels to storage areas or drug
labels to alert staff that they're dealing
with drugs that are often confused with
other agents.
• Invest in safety solutions. Consider
adding safety tools such as barcode-assist-
ed syringe labeling and electronic anesthe-
sia documentation systems. Point-of-use
barcode technology can provide audio and
visual confirmation of scanned drugs, auto-
matically generate accurate and legible
labels you can affix to syringes, and track
the medications used during cases. It's a
high-tech way to confirm that the right
drug is reaching the right patient at the
right dose and at the right time. In addition,
pre-packaged medications and pre-filled
syringes come properly labeled and essen-
tially reduce the risk of dosing mix-ups and
cross contamination risks that endanger
patients.
• Secure controlled substances.
Surgical tech Rocky Allen recently pleaded
guilty to replacing fentanyl syringes with
SAFE & SECURE
4 Medication Safety Essentials
