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Archive October 2019 XX, No. 10

Strategies for Better Medication Management

Developing a comprehensive protocol for OR medication administration can fill holes that lead to errors — and uncover ones you knew nothing about.

Joyce Wahr Wahr

Joyce Wahr Wahr, MD


LESSONS LEARNED Take a non-punitive approach to improving medication safety, because human error is the root cause of most administration errors.

Medication errors are all too frequent in the OR. A recent observational study identified an error in 5.3% of all anesthesia medication administrations — roughly 1 of every 20 — with about 80% of those errors deemed preventable. Why do so many medication errors still happen? Perhaps because, unlike all other locations in the hospital, the anesthesia provider is typically the only practitioner involved in determining what medication is needed, and then dispensing and administering that medication.

The problem of administration errors concerned our team so much that we researched all the available literature and organizational guidelines we could find that touch on medication safety. After whittling down all of the tips and findings we uncovered, we were left with 35 unique medication safety recommendations that all surgical facilities should consider in order to assess and correct vulnerabilities. (Our complete paper is at In this article, we'll briefly cover some of the most important ones.

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