tem, because you can also program in alerts. If, for example, you're
about to give a patient morphine, but the patient is allergic to mor-
phine, the system can warn you.
Nothing is fail-safe, but the best way to lower the risk of medica-
tion errors in the OR is to have prefilled, prelabeled syringes that
must be scanned before they're used. Unfortunately, none of those
things will actually prevent someone from administering the wrong
drug. Providers need to acknowledge and openly address the fact
that vigilance-based care is limited by human frailties. In other
words, engineering solutions and technological assistance are the
only ways to prevent medication errors.
OSM
J U L Y 2 0 1 8 • O U T PA T I E N TS U R G E R Y. N E T • 2 3
Dr. Litman (rlitman@ismp.org) is the medical director at the Institute for Safe
Medication Practices, in Horsham, Pa., and an anesthesiologist at the Children's
Hospital of Philadelphia.
