Medication Safety Products and Devices
It's time to stop blaming, and start implementing available solutions.
N
o one knows how often medication errors happen. A few stud-
ies suggest they're frighteningly frequent, but as long as we rely
on an honor system of self-reporting — and point fingers at
those who confess — we can guess that vast numbers of errors are
going to continue going unreported. People who fear reprisals or punish-
ments aren't likely to own up every time something happens.
Medication errors happen, in part at least, because, as we all know, the
operating room is a very complicated place. We're surrounded by equip-
ment and noise, and often the room is dimly lit. It's also a high-stress
environment, which increases the potential for errors. But I'd bet that in
many cases, very similar types of drug errors may be occurring again
and again within the same institution, and that relatively simple solu-
tions exist to correct at least some of those errors — if only they were
reported. As such, we should be encouraging reporting in a blameless
society, so we can do root-cause analyses and implement the solutions
we need.
For several years, the Anesthesia Patient Safety Foundation has
advocated using point-of-care scanners to confirm and document
every drug administration. So far, a relatively small number of facili-
ties have adopted that approach, but many seem to be moving in that
direction.
Meanwhile, it's a little shocking how few providers are aware of USP-
797 and its implications on point-of-care drug compounding. USP- 797,
the only chapter of the U.S. Pharmacopeia that applies to individuals
compounding drugs, makes it very clear: Except in emergencies,
syringes should be filled only in a sterile environment under a laminar
flow hood. So the trend toward prefilled syringes is a big step in the
right direction. Not only are they USP 797-compliant, but they also
1 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • M a y 2 0 1 7
Thinking of Buying …
Eugene R. Viscusi, MD
