The problem of administration errors concerned our team so much
that we researched all the available literature and organizational
guidelines we could find that touch on medication safety. After whit-
tling down all of the tips and findings we uncovered, we were left
with 35 unique medication safety recommendations that all surgical
facilities should consider in order to assess and correct vulnerabili-
ties. (Our complete paper is at osmag.net/bZ7WgJ.) In this article,
we'll briefly cover some of the most important ones.
• Accurate patient information. Before administering medications
in the OR, you need a complete, accurate medication reconciliation
for the patient. All medications should be entered in a standard for-
mat in the patient's chart, and have a single location for recording
medications administered across the surgical process, including pre-
op and PACU, to avoid errors like double-dosing. Pre-op time outs
should include the patient's weight, allergies and medication informa-
tion such as which antibiotics have been given and when redosing
would be needed. Anesthesia providers must be familiar about any
patient condition or medication, such as allergies and drug-drug inter-
actions, that could affect the types or dosages of medications to be
administered.
• Culture change. One of the most commonly mentioned recom-
mendations in the literature and in guidelines is that every institution
needs to have a non-punitive incident reporting system for the report-
ing and analysis of medication incidents, whether they harmed a
patient or not. Medication safety requires a culture change, where
there is respect and collaboration rather than judgment; you don't
want people to feel badly about mistakes, nor do you want staff mem-
bers to hesitate to report their colleagues for fear of getting someone
else in "trouble" (unless it's a willful violation). Each institution
should establish a voluntary, blame-free, non-punitive system for error
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