Medication error is defined as an error occurring anywhere in the medication use process.1 In the United States, it is estimated that preventable medical errors are responsible for 100,000 to 400,000 deaths per year, with almost 10%-15% of these deaths due to medication errors.2 The true incidence may even be higher, as most of the errors go unrecognized or unreported by providers. Medication errors can lead to significant morbidity and mortality. They are also a huge financial burden to the institutions themselves, which may spend over $40 billion a year to treat them.3,4 Although most errors lead to minor injury, some have the potential to be fatal,5 and others can lead to decreased patient satisfaction or loss of trust in the health care system. Other unintended consequences of trying to address medication error can include escalating costs, increased health disparities, complacency, negative changes in provider behavior, and misalignment with patient preferences.6 

The OR is a unique environment where an anesthesia professional is the only person involved in the entire process of prescribing, dispensing, formulating, administering, and documenting the medication, often without a formal check with another person on any of these actions. It has been estimated that one drug error occurs for every 133 anesthetics, and 1% of these errors cause harm to patients.7,8 One prospective study in anesthesiology found that one in 20 perioperative medication administrations resulted in a medical error or an adverse drug event; 79.3% of which were deemed preventable.9 

Over the past several decades, multiple professional societies, patient safety organizations, regulatory agencies and medication safety publications have proposed strategies, interventions, and practice changes for improvement to the perioperative medication use process. While we have made significant strides to improve medication safety, medication errors remain a persistent and concerning source of patient harm throughout the world.4,10 

Although some of these interventions have decreased medication errors, others may inadvertently worsen medication safety. Three examples follow.

Prefilled syringes are produced by manufacturers with standardized labelling and can replace provider preparation of anesthetic medications in the OR.11,12 The purchasing pharmacy technician team accidentally ordered a higher concentration of phenylephrine prefilled syringes (80 mcg/mL) and programmed the automated medication dispensing system (AMDS) incorrectly, with the higher concentration programmed as the original lower concentration (40 mcg/mL). It took three weeks before anyone noticed and reported the incorrect concentration. A temporary solution involved asking anesthesia professionals to use the automated medication labeling system to create a new label for the prefilled syringe, providing auditory and visual confirmation of the concentrations in the prefilled syringes.12 

There are many different medications to set up and administer in cardiac ORs. An institution therefore created a specialized cardiac medication box that could be picked up from the inpatient pharmacy to ensure a complete inventory of medications that might be needed. The components were predetermined and consistent. Two medications, phenylephrine and insulin, looked very similar and held the same volume. The anesthesiologist set up infusion pumps prior to the case without realizing that there were two insulin bags instead of insulin and phenylephrine. During the case, they meant to titrate phenylephrine for hypotension but actually gave the patient increasing doses of insulin. Fortunately, this situation was identified promptly due to lack of desired medication effect, but it could have caused severe harm. Subsequently, the insulin formulation was switched to a different volume and label for OR use.

Phenylephrine infusions with a concentration of 40 mcg/mL are compounded by the pharmacy for use in the OR. The rest of the institution (the emergency department and intensive care units) uses a phenylephrine concentration of 400 mcg/mL. Both concentrations utilize standard white medication labeling. Only the lower concentration phenylephrine bag should be available in the core AMDS within the ORs. The AMDS is designed such that the technician only needs to scan one bag before adding all the bags to the appropriate slot within the AMDS. In this situation, 400 mcg/mL bags were mixed in with the 40 mcg/mL bags by mistake. An anesthesiology resident inadvertently obtained a 400 mcg/mL bag but set the infusion pump at 40 mcg/mL, resulting in iatrogenic hypertension. After a root cause analysis and extensive research on peripheral vasopressor extravasation and adverse events, a decision was made to remove the 40 mcg/mL concentration, and the 400 mcg/mL concentration was standardized throughout the hospital.

As seen through these examples, there are many unintended consequences from intended safety interventions such as prefilled syringes, premixed medication bags, standardized labeling, white medication labels, and standardized concentrations. There are several causes for these medication errors.

First, errors are significantly underreported in the perioperative setting. Studies suggest that medication errors occur frequently and are preventable.9,14 Anesthetized and mechanically ventilated patients are tolerant to many medication errors, and only a minority of cases with poor outcomes are subject to formal review by the institutions.15 As a result, comparing error rates may not be a valid way to determine if a given strategy lowers errors.

These cases demonstrate that medication interventions are often implemented based on institutional expert opinions (such as selecting the single concentration of phenylephrine bags), case reports, or data from other institutions (“this is how others do it”). Hospitals need to develop creative solutions to encourage people to double-check themselves, although these behaviors can fade over time (as noted in the example with the prefilled phenylephrine syringes).

The national societies that make many of the recommendations to reduce medication errors are based on expert opinions. However, sometimes even expert opinions can be at odds with each other. For instance, some recommend using white labels for medications to encourage providers to read labels, whereas others advocate for color-coded medication labels.16 

There are other options besides expert opinion. Randomized controlled trials on safety strategies are the preferred method for scientific evidence, but safety trials are difficult and expensive to conduct. Simulation is another means to test interventions but simulation trials in medication safety have not been widely used. Comparing results of newly initiated medication strategies from a pre-implementation to post-implementation phase can also be used. These comparisons can be particularly suitable for technological safety additions, such as bar code scanning. Chart reviews can also serve as another means to find medication errors to help evaluate effectiveness of selected safety strategies.17,18 Because of these barriers, relying on expert opinion for perioperative medication safety recommendations is a reasonable alternative when evidence is limited.17,18 

Further, the combination of the complex health care system and human behavior can easily lead to unintended errors. Post-pandemic, anesthesiologists are stretched as thin as they have ever been and are expected to produce more with fewer resources. Patients now require increasingly complex preoperative, intraoperative, and postoperative care, with many time-consuming elements such as extensive preoperative interviews, code status discussions, conditioning testing, nerve blocks, and difficult airways. Administering medications sometimes may seem like the most straightforward part of the job, but this mindset can lead to complacency. Additionally, with the introduction of pharmacy-prepared prefilled bags and syringes, anesthesia professionals may feel complacent if the system seems infallible – as demonstrated in the examples above.

“Over the past several decades, multiple professional societies, patient safety organizations, regulatory agencies and medication safety publications have proposed strategies, interventions, and practice changes for improvement to the perioperative medication use process. While we have made significant strides to improve medication safety, medication errors remain a persistent and concerning source of patient harm throughout the world”

The Institute for Safe Medication Practices (ISMP) has assembled information from a perioperative safety assessment, literature review, ISMP's clinical consultant observations, and expert feedback to identify practices with the biggest opportunity for safety improvement. Seventy-one statements were prioritized to form the ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.19 The Table summarizes a subset of the frequently suggested approaches to improve perioperative medication safety from across multiple organizations, societies, groups, and publications.

Table: A summary of key elements from the ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.19 

Table: A summary of key elements from the ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.19
Table: A summary of key elements from the ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.19

The ISMP medication guidelines make it clear that multiple multidisciplinary interventions are necessary to move toward increased medication safety.

There are some things that anesthesiologists can do as clinicians and leaders to move medication safety forward. This includes cultivating a culture of safety and promoting psychological safety such that clinicians can feel comfortable reporting medication errors.20 We should discourage the criminalization of medication errors at a national level.21 Departments can also consider implementing mandatory error reporting systems for every anesthetic procedure.22 Dedicated time for reporting will also increase the likelihood of successful interventions.

Accruing accurate data facilitates studying interventions and their effects more systematically. This may take the form of pre- and postimplementation studies or via randomized controlled trials. When implementing bundles of care, it is increasingly important to study the potential effect of each individual intervention to determine which ones increase medication safety with the least amount of effort. Safety is an iterative process that requires reexamination of implemented tools over time. As with prefilled syringes and the prepackaged cardiac box, anesthesiologists can become complacent if they believe that one solution is the end of that problem. A loop of reporting, learning, transparency, and feedback can encourage reported near-misses to allow adjustment prior to harm (Figure).23 Ultimately, we need to remain ever-vigilant that our “fixes” don't end up causing additional problems. Clearly, there is much still to do to improve medication safety – we have not yet found “the golden ticket.”

Figure: Learning about and fixing systems issues begins with front-line clinicians reporting adverse events and near-misses. Changes that result from reports should be communicated back to clinicians to encourage continued reporting.

Figure: Learning about and fixing systems issues begins with front-line clinicians reporting adverse events and near-misses. Changes that result from reports should be communicated back to clinicians to encourage continued reporting.

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Karolina Brook, MD, FASA, CPPS, ASA Committee on Patient Safety and Education, Secretary, Massachusetts Society of Anesthesiologists Executive Committee, Assistant Professor of Anesthesiology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, and Director, Quality and Safety, Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts.

Karolina Brook, MD, FASA, CPPS, ASA Committee on Patient Safety and Education, Secretary, Massachusetts Society of Anesthesiologists Executive Committee, Assistant Professor of Anesthesiology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, and Director, Quality and Safety, Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts.

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James Dierkes, MD, MBA, ASA Committee on Patient Safety and Education, ASA Committee on Occupational Health, ASA Committee on Young Physicians, and Anesthesiologist, Providence Anesthesiology Associates, Charlotte, North Carolina.

James Dierkes, MD, MBA, ASA Committee on Patient Safety and Education, ASA Committee on Occupational Health, ASA Committee on Young Physicians, and Anesthesiologist, Providence Anesthesiology Associates, Charlotte, North Carolina.

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Tricia A. Meyer, PharmD, MS, FASHP, FTSHP, APSF Education and Training Committee, APSF Newsletter Editorial Board, and Adjunct Professor, Department of Anesthesiology, Texas A&M University School of Medicine, Temple, Texas.

Tricia A. Meyer, PharmD, MS, FASHP, FTSHP, APSF Education and Training Committee, APSF Newsletter Editorial Board, and Adjunct Professor, Department of Anesthesiology, Texas A&M University School of Medicine, Temple, Texas.

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Uma Munnur, MD, MS, ASA Committee on Patient Safety and Education, and Professor in Anesthesiology, Baylor College of Medicine, Houston, Texas.

Uma Munnur, MD, MS, ASA Committee on Patient Safety and Education, and Professor in Anesthesiology, Baylor College of Medicine, Houston, Texas.

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