7. Know the route. "Some of the most catastrophic events occur
when perfectly prepared medications are administered by the wrong
route," says Dr. Wahr. She recalls when an epidural bupivacaine infu-
sion intended to enter the epidural space at a low rate was mistaken for
an antibiotic and administered to a pregnant woman. The baby was
saved, but the mother died. Route-specific connecting systems — enter-
al and near neuraxial — are now available to ensure medications are
administered the correct way. "The best thing to do, as quickly as possi-
ble, is to start using those unique infusion lines," says Dr. Wahr.
Prevent defense
Keep in mind that Mass General, a national leader in patient safety,
had already implemented processes to improve medication delivery in
the OR when the study took place. So it's safe to say medication error
rates are probably at least as high at your facility.
"There's definitely room for improvement in efforts to prevent peri-
operative medication errors," says Dr. Nanji. "Identifying the types of
errors that are being made allows for the development of targeted
strategies to prevent them from happening."
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