incident reporting,
analysis and interven-
tion. No one begins
their day by planning
to make mistakes;
similarly, it is highly
unlikely that a
provider who makes
an error doesn't care,
so they cannot be
labeled as "careless."
We are all subject to
human vulnerabilities, experience fatigue, pressure and distractions,
and are at risk of making an unintended error. Incident reporting and
analysis should never seek someone to blame, but focus on how the
system failed, and how vulnerabilities can be reduced. Create an envi-
ronment where if somebody makes a mistake, that person feels com-
fortable reporting it to their superior; the end result should be that the
entire team huddles to discuss how to prevent a similar mistake from
occurring.
Teams should develop easily accessible written policies for medica-
tion safety, and stress their importance when orientating new staff.
Adequate supervision, teaching and in-service training must be provid-
ed. Leaders should create and nurture an environment that helps peo-
ple change their attitudes, habits, skills, and ways of thinking and
working around medications. Once we recognize how patients are
vulnerable to medication error, we should all be willing to improve
our practices.
• Pharmacy assistance. Medication in the OR requires close collab-
oration with your pharmacists. They should spend some time with
5 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 9
• VISUAL AID Color-coded labels are safeguards against mixing up medications at
the sterile field.
Pamela
Bevelhymer,
RN,
BSN,
CNOR
