The unique environments of the operating room (OR) and procedural areas require medication-use processes that differ from methods traditionally used in the inpatient units. As such, this distinct setting requires a special approach to medication management for all relevant staff, including surgeons, anesthesiologists, pharmacists, and OR and PACU nurses. While multiple resources and guidelines are available to help structure medication management in the perioperative setting, including ASHP Guidelines on Surgery and Anesthesiology Pharmaceutical Services,1 the Anesthesia Quality Institute,2 the Surgical Quality Alliance,3 the Anesthesia Patient Safety Foundation (APSF),4 and the Association of PeriOperative Registered Nurses (AORN),5 it is critical that organizations put these resources to use and develop a strategy to ensure safe access to medications in the OR and procedural areas.
Duke University Hospital, a tertiary and quaternary care hospital, is licensed for more than 1,100 beds and operates over 50 ORs, comprising the major surgery suite, an ambulatory surgery center, and an eye surgery center. Four on-campus OR satellite pharmacies manage the medication-use process in each of these platforms. Excluding the ambulatory surgery center, 7.2 clinical pharmacist and 10.7 pharmacy technician FTEs cover operations for three of the satellite pharmacies, one of which operates 24/7. Effective medication management in the OR environment is a primary goal at Duke.
Stages of the Medication-Use Process
The medication-use process can be broken into five sequential stages: prescribing, transcribing, dispensing, administering, and monitoring. In an inpatient unit, this sequence of events may take minutes to hours to complete depending on the scenario. However, in the perioperative environment, the medication-use process typically moves more quickly. Factors influencing this difference include the number of involved personnel, as well as the number of safety measures in place to minimize the risk of errors (eg, the use of automation, such as bar code scanning). FIGURE 1 demonstrates the general differences between each process.
The traditional medication-use process typically involves various staff members at each step, which helps ensure medication safety through multiple safety checks. This differs within the anesthesia setting, where fewer providers are responsible for all the steps within the process. Without these additional safety checks, often it is left to the providers alone to ensure they have selected, prepared, labeled, administered, monitored, and documented appropriately. The lack of multiple safety checks from various individuals or systems (eg, bar code scanning) increases the risk of error.6
Medication Safety Risks
Human error in the anesthesia administration process is a leading cause of adverse drug events.7,8 One prospective, observational study reviewing anesthesia medication errors demonstrated a reported incidence of 1 error for every 203 cases.9 In another review of published costs of medications errors leading to preventable adverse drug events in the US, the per-hospital cost ranged from $600,000 to $5.6 million.10
Safety risks associated with anesthesia practice include (but are not limited to): syringe swaps, incorrect syringe labeling, incorrect vial selection (look-alike errors), incorrect injection sites, infusion pump programing errors, incorrect dosing, omission errors, repetition errors, and substitution errors.7 Syringe swaps, incorrect syringe labeling, and vial selection have been documented as causing approximately 50% of medication administration errors in the OR.7 In order to mitigate these risks, each institution must assess the feasibility of implementing evidenced-based strategies that reduce medication administration errors involving anesthesia.
With the assistance of an interdisciplinary team, pharmacy oversight in the perioperative environment can improve medication security, charge capture, cost management, and controlled substance management, and ensure compliance with regulatory standards. Additional benefits include greater pharmacy visibility and enhanced clinical services in the perioperative environment, as well as increased collaboration with perioperative leadership. With these benefits in mind, it
behooves a hospital to carefully evaluate the possibility of implementing an OR pharmacy satellite. Some variables to consider when conducting an evaluation include hospital size, the level of pharmacy labor and staffing that will be required, the clinical pharmacy services that will be offered, OR workflow, available storage and work space, and hours of service. See TABLE 1 for a summary of recommended strategies to ensure a safe medication-use process in the OR environment.
In the OR and procedural suites, it is rare for an anesthesia provider to submit a medication order that then flows through the traditional medication-use process. Rather, anesthesia providers usually request needed medications prior to the beginning of each case. Medications may be provided via a medication tray, cart, or box stocked with standard medications that are supplied for each case. These medications may be sourced directly from pharmacy, from a centralized automated dispensing cabinet (ADC), or via an anesthesia cabinet at the bedside. Factors in determining which method to use include evaluating the associated safety risks, cost (FTE, supply, and avoidance of safety events), logistics, medication security, timely access, controlled substance (CS) management, and sufficient storage space for medications and the respective trays or carts.
Duke utilizes multiple processes for supplying medications to anesthesia (see TABLE 2).
Transcribing and Dispensing
Because anesthesia typically does not utilize written orders for medications in the OR and procedural areas, transcription of medication orders is infrequent. However, there may be cases in which hospital policy or protocol dictates that certain medications utilize written orders (eg, blood factors or compounded sterile preparations). In this case, utilization of CPOE and standardized order sets is recommended to reduce transcription errors. If CPOE is unavailable, standard order sets should be used to reduce transcription errors and improve safety for ordering the selected medication.
If a medication is readily available at the patient bedside as a standard stock item, it is recommended that pharmacy provide single-dose vials or unit-of-use options (eg, prefilled syringes) for all products, if feasible. Unit-of-use medications may have higher costs compared to commercially provided single-dose vials; therefore, hospitals should evaluate the total cost of providing these options and compare this cost against the potential cost avoidance of reducing medication errors by providing unit-of-use products.
Standardize labeling of medications by pharmacy and at the bedside by anesthesia providers. Label formats must be clear and complete, and include, at a minimum, all regulatorily required information. Color-coding by drug class utilizing national/international standards is recommended only for user-applied labels in the OR, because the use of color-coding may lead to providers selecting medications by color instead of reading the full label description, which, in turn, can lead to medication administration errors. For this reason, color-coding of commercially prepared products is opposed by ISMP, ASHP, and other pharmaceutical scientists.11,12 ISMP recommends that outsourced vendors who repackage color-coded syringes apply a warning to the product indicating that the medication is for use by anesthesia in the OR environment only.11
As previously mentioned, the following recommendations assist with improving safety during dispensing:
However, these recommendations are dependent on available staffing and resources and may prove challenging to implement. Developing a system that allows tracking and reporting of these safety steps (bar code scanning and independent double-checks) assists in trending what opportunities exist within the organization. Because many institutions do not utilize bar code scanning in the OR, tracking and trending may be challenging without the aid of an automated system.
In the OR and procedural areas, a single anesthesia provider often is responsible for administering most, if not all, medications to the patient. This scenario clearly begets a need for additional safety checks during the administration process. However, it is important to consider anesthesia workflow when implementing a proposed solution.
Anesthesia providers focus on monitoring and maintaining certain levels of sedation, neuromuscular blockade, or analgesia. To accommodate their workflow, it is suggested that providers have a uniform arrangement of medications, syringes, and empty drug containers in the work space, which can reduce selection errors during the administration process. In addition, implementing double-checks of prepared medications or of an infusion device to ensure it is set up correctly, just prior to administration, is recommended.13 However, as is the case during medication dispensing, this can be a challenge if the necessary staff and resources are lacking.
Monitoring, the last step of the medication-use process, should be reviewed from two angles. The first, and more active approach, involves the anesthesia provider performing continuous patient monitoring during a specific patient case. Anesthesia should have sufficient resources and equipment available to accurately assess patient responses to administered medications, as well as a method of documenting and easily retrieving information about medications administered and their associated patient responses.
The second approach is the quality review of individual patient cases when errors are identified. It is important for an institution to promote non-punitive error reporting to increase reporting rates, as well as to identify breakdowns in the medication-use process. An interdisciplinary approach to reviewing these reports fosters an environment in which the institution can review the full extent of the medication-use system and identify solutions that may be specific to one practice group or extrapolated to multiple groups and services.
Because one anesthesia provider may be responsible for the entire medication-use process, it is imperative to implement safety checks for every step, including prescribing, transcribing, dispensing, administering, and monitoring, to reduce the risk of medication errors. Effective strategies to ensure safety in the OR environment include increasing standardization, utilizing CPOE to its full capacity, proactively reporting errors, and implementing ongoing interdisciplinary quality review of anesthesia medication practices. While providing appropriate oversight of medications used in the unique OR environment may seem daunting, it is critically important that pharmacy provide effective management for anesthesia drugs, just as in all other areas of the hospital.
Previously the manager of perioperative pharmacy services at Duke University Hospital, Christopher Murray, PharmD, MS, is now the market director of pharmacy at CHI St. Luke’s Health Memorial in Lufkin, Texas. Christopher received his PharmD from Hampton University in 2008, along with a minor in leadership studies. He also completed a health system pharmacy administration residency at Duke University Hospital from 2008 to 2010. Christopher’s professional interests include pharmacy leadership, mentorship, and medication safety.