Archive May 2014 XV, No. 5

The Real Consequences of Medication Errors

Focus on proper labeling, smart storage and constant communication to protect patients from harm.

Matthew Fricker Jr., MS, RPh, FASHP


label syringes immediately QUICK DRAW Label syringes immediately before or after filling them with medications.

Years later, he can't recount that day without choking up. "I don't think anyone would have suspected this little child — a very healthy child — on that given day, coming in for a very elective surgery, would not leave the hospital alive," says George McLain, MD, an anesthesiologist at Martin Memorial Health System in Stuart, Fla.

Medication vials were unmarked on the sterile field. The surgeon injected 9-year-old Ben Kolb with what he thought was lidocaine with dilute epinephrine. Unfortunately, sadly, it was concentrated 1:1,000 epinephrine.

"When we started doing CPR and the child did not come right back, I didn't feel a sense of panic, but a sense of dread," recalls Dr. McLain. "It was very difficult to see a child die right before your eyes."

Persistent problems
Don't think that devastating result could happen to you? Think again. Here are medication issues I've seen repeatedly in ORs while consulting with facilities for the Institute for Safe Medication Practices.

  • Labeling. Clearly and completely label all medication containers and syringes. A pair of anesthesia partners at a hospital didn't label drugs in the sterile field because they had a system in place that involved drawing certain drugs into specific-sized syringes. During a presentation about the dangers of this practice, the anesthesiologists' faces turned white. They both relied on the same system for identifying medication, but did so with different medications. What would have happened if one of the partners couldn't complete a case and the other had to step in? Labeling systems needs to be standardized so everyone's on the same page and caregivers can provide safe patient care no matter which OR they step into and when during the case they intervene.

I've seen anesthesia providers properly label all syringes except those containing propofol, because they argued there was no other drug that resembled the milky white substance. But now Exparel and lipids are more common in ORs, and both look identical to propofol. Providers need to label all syringes prepared for use during procedures.

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