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Archive Anesthesia 2018

Tools to Improve Medication Safety

To eliminate administration mistakes, you have to eliminate the human factor.

Ronald Litman

Ronald Litman, DO, ML


HUMAN ERROR Well-intentioned surgical team members check and recheck labels, but medication administration mistakes can still occur.

Only in the OR can you prescribe, prepare and administer medications with no input from a second provider and no electronic clinical-decision support — and often under stressful or chaotic conditions. What could possibly go wrong?

You guessed it: plenty. Surgical teams administer the right medication to the right patient at the right time most of the time, but when things go wrong, as they inevitably do, the consequences can be cataclysmic. I once investigated a case in which an 11-year-old boy died because his anesthesiologist meant to give him ondansetron, but accidentally gave him phenylephrine, a blood pressure-boosting drug, because the similar-looking vials were next to each other in the anesthesia drug tray. Not only was it the wrong drug, but phenylephrine is so concentrated that it requires a 100-fold dilution. The mistake caused the child to have severe hypertension and a pulmonary hemorrhage. His young life ended the next day.

You need to eliminate the human factor in order to prevent such a devastating mistake from happening on your watch. Unfortunately, that's easier said than done.

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