Medication use in the perioperative setting is of paramount importance. In general, medication management in this setting is both challenging and essential, given the number of high-risk medications used, the variety of practitioners accessing these medications, and the vulnerable nature of surgical patients. The inclusion of children and young adults in this population means the potential for risk is even greater. It is with this in mind that the Texas Children’s Hospital pharmacy department, in collaboration with anesthesia, nursing, and surgical practitioners, evaluated and incorporated automation and standardized labeling technology early in 2013.
Over the past year, we have implemented and integrated automated anesthesia workstations and automated medication labeling systems in the effort to automate medication management and distribution in operating room (OR) areas and mitigate the bulk of our risk points. The most significant areas of risk were identified during the lead up to implementation, and included proper storage, preparation, and dispensing of high-risk medications in all perioperative areas. Each of these risk points was impacted by our approach to labeling and bar code identification of all medications used. We have found that through proper and consistent use of these automated devices, we have been able to increase safety and decrease risk in the OR.
Before the implementation of automation technology, medications were provided to perioperative areas via kits, trays, boxes, and anesthesia-specific fanny packs. These practices raised concerns because most perioperative medications are high-risk, including anesthetics, anticoagulants, benzodiazepines, electrolytes, neuromuscular blockage agents, paralytics, sedatives, and vasopressors. Under our prior process, many high-risk medications were manually stocked in the kits, trays, boxes, and fanny packs, which were signed out to OR personnel according to the daily surgical schedule. Given the sensitivity of perioperative medications, compounded by the risks of labeling or identification errors in a manual distribution process, along with the potential for diversion, the need for automated medication management in the OR was glaring.
Inside the OR, medication doses are often calculated and prepared in advance, with some final dilutions performed prior to administration. Before the implementation of the anesthesia workstations and the automated labeling system, medication labels were pre-printed and stored in drawers together with the medications. Because there were no automated mechanisms in place to ensure medication syringes were labeled appropriately or that the labels were clear and legible, there was undue potential for medication errors, especially for look-alike, sound-alike drugs. Furthermore, the lack of standardized labels meant that medications requiring further dilution steps could potentially be prepared incorrectly.
Effects of Automation
Among the goals of this project was to integrate medication management systems that would bring us inline with The Joint Commission’s National Patient Safety Goals for safe medication use processes. The automated labeling system we selected follows the American Society of Anesthesiologists’ (ASA) color guidelines and the American Society for Testing and Materials (ASTM) standards (see SIDEBAR).1 The system is also able to receive data imports from a nationally recognized electronic drug formulary service, which facilitated configuration of the drug database. The automated labeling devices were implemented at the same time as the anesthesia workstations in the OR department, and because pharmacy supports both technologies and their associated medication databases, we coordinated the training process to take place over the course of several weeks so that all affected staff would have ample time to become familiar with the new processes. Due to the range of practitioners that would be affected by this new workflow, we designed a training program that would provide hands-on instruction to all staff that would interact with the automation, including anesthesiologists, nurses, pharmacists, physicians, and OR support personnel.
Gaining acceptance for the OR automation was challenging initially, given staff concerns that the technology could negatively affect workflow. In addition, some staff members expressed a lack of comfort with the new technology. However, the enhanced safety provided by the OR automation was widely recognized, ultimately overcoming the initial reticence of certain health care providers. Throughout the implementation process, we encouraged input from multiple team members, which further increased staff confidence. The increased availability of medications, streamlined paperwork process, and minimized workload were among the most important benefits of the technology. Data were reviewed by the Pharmacy and Therapeutics committee, and members of the medical staff agreed with the chair of the Anesthesiology Quality and Safety committee that the use of these technologies would contribute to a safer environment.
Controls and Processes
Both systems (the anesthesia workstations and the automated labeling system) have provided significant safety and inventory management improvements in our OR medication workflow and addressed the bulk of our risk points. All medications are now stored in the workstations and all nurses, anesthesiologists, and physicians use personal login codes to access the workstations, enabling medication accountability and tracking. Through this system, pharmacy retains control over and helps establish usage protocols, restocking requirements, and expiration tracking. The processes involved in medication preparation also have improved now that we have labels with consistent naming conventions and concentrations, which help ensure safe dilutions.
Automated dispensing of perioperative medications, in coordination with standardized bar coding technology, has given us the peace of mind that the correct medication is prepared and administered to the patient every time. Upon removing a drug from the anesthesia workstation, the nurse or anesthesiologist scans the vial using the labeling system (mounted on the workstation) to positively identify the drug and verify that it is correct. The user then selects and removes a dilution (configured by pharmacy), if appropriate, from the workstation. Once the medication is prepared and ready, the labeling system produces a standardized, bar coded label, eliminating the need to manually add a second bar code label to the final product. Upon administration, the medication label prepared by the labeling system is scanned again for additional verification prior to the drug being administered to the patient.
Given the risks inherent to most perioperative medications, manual management—including stocking, tracking, labeling, dilution, and administration—is rife with potential for error. Mistakes made in the OR have a high potential for patient harm, so it is particularly important to introduce standardization and automation in this environment. Likewise, taking into account the number of different health care practitioners working in the perioperative setting, it is vital that these groups work together cohesively utilizing common technologies. At Texas Children’s Hospital, automation for the management of anesthesia and related products has addressed our points of risk and has improved medication safety in the perioperative setting.
Gee Mathen, BS, is an assistant director of pharmacy for application and technical services at Texas Children’s Hospital. Gee received his BS in industrial engineering from the University of Houston. His professional interests include robotics in medication delivery, data-mining and warehousing, and automation technology in medication management.
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