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Optimizing Drug Safety in the Operating Room

By: Maryam Ahmed, PharmD Candidate c/o 2016

While hospitals are a place where people can get their ailments cured, there is still room for improvement. According to the Institute of Medicine, over 1.5 million Americans are injured in hospitals each year.1 Hospital protocols are implemented to keep these errors to a minimum in order to optimize drug safety, specifically in the fast-paced operating room setting.

According to a 2004 United States Pharmacopeia study, medication errors do not necessarily result in harm.1 Despite this, attention to detail and practitioner experience are required for safe and effective use of certain medications, especially in the perioperative setting. Increased awareness is essential when dealing with common high-alert medications, such as anticoagulants, anesthetics, cardiovascular drugs, anxiolytics, neuromuscular blocking agents, and opioids. To aid in minimizing adverse events, single dose containers should be supplied, as these agents can cause severe consequences if improperly administered. Hospital staff, especially nurses, should also be responsible for ensuring proper monitoring and support for all high risk medications.2

Verbal orders are another common cause of medication errors. The use of technology through the practice of computerized physician order entry, which potentially recognizes dosing errors and reduces transcription errors, is a strategy to help minimize errors previously caused by verbal orders, and to optimize safety.1 Computerized medication orders, barcode technology, and color coded labels are a few advancements that can be utilized to prevent errors. Implementing technology like this allows the healthcare team to focus their attention towards verifying the appropriateness of an order, rather than the actual delivery, which will ultimately aid in error reduction.

To determine the overall impact of a computerized system, a retrospective analysis of two hospitals in Melbourne, Florida was conducted using 359 incidence reports. The first hospital utilized a pen and paper system, while the other had just recently implemented a new medication management system. The results illustrated that at each site, there was a different cause of errors. At site A, omission (33%, possibly from verbal orders) was the main cause of errors, whereas incorrect documentation (24.4%) was the main concern at site B. It is possible that a portion of the errors at the computerized site may have been due to lack of experience with the new system, indicating a limitation of this study.

Since there were no uniform errors at both sites, it is difficult to draw a conclusion in regards to which system is superior, but this study did allow us to draw the conclusion that “the incidence of other, less frequent errors was similar across the two hospital sites.”3 Although the type of errors and where they occurred varied, the incidence was relatively the same, and did not provide any clinical significance.

Regardless of the system that a hospital uses, basic safety protocols should be followed. Careful labeling of drugs with the drug name, concentration, and beyond use date are minimum safety requirements. In addition, any un-readable drug or unlabeled drug should be properly disposed.1

If proper safety protocol is applied, in addition to the above recommendations, adverse events and medical errors can be drastically minimized.



  1. McAllister R, Meyer T. Strategies for Optimizing OR Drug Safety. Pharmacy Practice News. http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Special+Edition+%2f+Educational+Reviews&d_id=63&i=December+2014&i_id=1130&a_id=29028. Published 12/01/2014. Accessed 03/12/2015.
  2. Hicks R, Wanzer L. Medication safety within the perioperative environment. Annu Rev Nurs Res.  2006; 24:127-55. http://reference.medscape.com/medline/abstract/17078413.
  3. Botti M, Redley B. Reported Medication errors after introducing an Electronic Medication Management System. J Clin Nurs. 2013; 22(3-4):579-89.
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