Access Now: AORN COVID-19 Clinical Support

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.

New to Outpatient Surgery Magazine?
Sign-up to continue reading this article.
Register Now
Have an account? Please log in:
Email Address:
  Remember my login on this computer

advertiser banner

Other Articles That May Interest You

Anesthesia Alert

Anesthesia Machines Provide Life-Saving Support

Primed for Recovery

Optimizing patients' nutrition before surgery prepares their bodies for the physical rigors of surgery.

Anesthesia Alert: Predicting Post-op Delirium Severity

New ways of using old screening tools can help you identify at-risk patients.