The volume of high-alert, high-risk medications used in the OR makes it one of the most medication-intensive areas of the hospital. Anesthesiologists prescribe, prepare, and deliver medications without the safety systems such as barcoding, pharmacy medication review, or electronic order checking that are common in other hospital locations. In addition to the task-intensive, high-stress, high-productivity nature of our specialty, the OR is a high-hazard area in which medication errors are more common and can cause severe harm (P T. 2018;43:129-67).

More than three dozen steps are required in order to administer a single medication in the OR. Anesthesiologists must frequently select the correct pre-prepared syringe from a variety of others on a cart or in a bin, thus increasing the risk of a syringe swap in which a different medication is administered than the one that was...

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