Reducing intraoperative medication errors
Myron Yaster MD and Lynn Martin MD
Over the past 2 years the Pediatric Anesthesia Article of the Day has reviewed several papers on how to reduce medication administration errors during the clinical practice of pediatric anesthesia. As most of the data generated is often reliant on self-reporting which will largely underestimate the real incidence, we don’t actually know how many medication errors or close calls actually occur in practice. It’s logical to assume that medication errors are more common in pediatric anesthesia compared to adults.(1) Why? Because in pediatrics we use weight-based dosing which requires calculations in various units of measure. Is the dose in micrograms or milligrams (and occasionally grams). Is it a fixed dose or dosed per kilogram? Infusions can be in a dose per minute or per hours. Does a stock solution or the unit dose in an ampule require dilution and is this dilution standardized across the ORs and institution? Is there a standard for medication syringe labeling? Today’s PAAD reviews how to decrease or eliminate these errors and are based on recommendations from the Anesthesia Patient Safety Foundation and Wake Up Safe. I’ve asked Lynn Martin who has been at the forefront at studying many of these issues and is a frequent contributor to the PAAD to assist. Myron Yaster MD
Original article
Sheri Jones-Oguh, Elizabeth M Elliott, Heather McClung Pasqualino, Kathleen Harris , Rebecca S Isserman. Medication safety in pediatric anesthesia: An educational review and a call to action. Paediatr Anaesth. 2023 Jan;33(1):17-23. PMID: 36239463
As anesthesiologists we administer drugs in a unique way. We order, dispense, prepare, administer, document, and monitorpatients by ourselves without the checks and balances used elsewhere in the healthcare universe. Elsewhere these steps are shared by physicians, pharmacists, and nurses.(2,3) Indeed, many think that how we do business is, well, nuts. Are there better and safer ways for us to work?
“In spring of 2010, Dr. Eichhorn, writing for the APSF, highlighted 4 top areas to focus efforts on medication safety: (1) Standardization, (2) Use of technology, (3) Prefilled syringes and Pharmacy-prepared medications and decision support, and (4) creating a just Culture for reporting and analysis of critical events”.(1,4) Sounds pretty reasonable. However, is a “just culture”, that doesn’t punish error reporting possible? I (MY) am skeptical, particularly at a time that internal error reporting systems have been weaponized even when they are supposed to be anonymous. I (LM) think it is possible (we have moved the needle on this in Seattle), but it takes a concerted effort, time and ultimately trust. Creating this safe workplace is a critical first step to better understand the type and frequency of medical errors and near misses. On the other hand, many medication errors may be preventable with the use of three techniques (1) prefilled medication syringes to avoid accidental ampule swap, (2) scanning a barcode at the time of medication administration to prevent syringe swap and to confirm proper dose, and (3) the use 2-person verification for accuracy of medication infusions.(5,6) (See PAAD “Trust but Verify” November 9, 2022)
Standardization particularly of drug concentration offers an opportunity to decrease medication errors.(1) Another idea championed by Grigg et al. in Seattle that we think should be universally adapted is a durable medication template designed specifically to separate medications as they sat atop the anesthesia cart.(7) This allows for medications to always be in the same location in every OR and may be most important during emergencies and when the primary anesthesiologist is relieved for a break, thus reducing cognitive load in times of crisis and leading to fewer medication errors.
We’ve discussed drug infusion errors in previous PAADs(November 9,2022 article: Raghavan KC). Drug “infusion safety in the perioperative environment can be improved by: (1) smart pumps for the delivery of medications and fluids, (2) standardize smart pumps in OR and nonprocedural locations, (3) standardize concentrations of continuous medication infusions for use in anesthesia and across units, (4) utilize centralized pharmacy preparation of continuous drips, and (5) analysis ofsmart pump data to evaluate clinician compliance and smart pump effectiveness.”(1)
As I (MY) discovered in Colorado, real-time barcode scanning at the point of care can also decrease medication errors without interfering with the anesthesiologist’s work flow.(8) The Codonics® Safe Labeling System (SLS) creates drug labels from medication ampule bar codes with a dated, color coded label that is compliant with all regulatory requirements. It also has a speaking auditory read back system to further reduce error. Tying these systems into the electronic anesthetic record with real time bar coding, drug libraries, and decision support make complete sense to us and are long overdue.
What do you think? How has your practice dealt with these issues? Let Myron know and we’ll publish in a reader response.
References
1.Jones-Oguh S, Elliott EM, McClung Pasqualino H, Harris K, Isserman RS. Medication safety in pediatric anesthesia: An educational review and a call to action. Paediatr Anaesth 2023;33:17-23.
2.Martin LD, Grigg EB, Verma S, Latham GJ, Rampersad SE, Martin LD. Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia. Paediatr Anaesth 2017;27:571-80.
3.Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology 2016;124:25-34.
4.Eichhorn JH. APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice. Anesth Patient Saf Found Newsl, , 2010:1-8.
5.Lobaugh LMY, Martin LD, Schleelein LE, Tyler DC, Litman RS. Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative. Anesth Analg 2017;125:936-42.
6.Raghavan KC, Burlison JD, Sanders II EM, Rossi MG. Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm. Pediatric Quality & Safety 2022;7:e596.
7.Grigg EB, Martin LD, Ross FJ, Roesler A, Rampersad SE, Haberkern C, Low DKW, Carlin K, Martin LD. Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study. Anesth Analg 2017;124:1617-25.
8.Thomas JJ, Bashqoy F, Brinton JT, Guffey P, Yaster M. Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability. Hosp Pharm 2022;57:11-6.