4. Strengthen handoff procedures. Mistakes made during
patient handoffs can lead to future medications errors. Always take a
few minutes to ensure transitions of care are done properly and the
needed information is shared among providers in different phases of
the perioperative pathway.
Checklists are very effective in ensuring a patient's medication histo-
ry, medication allergies and potential drug-drug interactions are cov-
ered, even in time-pressured environments. Also address medications
that have already been administered — antibiotics, anesthetics, nar-
cotics — so there's no chance of repeat dosing without knowledge of a
previous dose. Create your own checklist based on the medication
needs of your patient population and the specific types of surgeries
your facility hosts.
5. Avoid common pitfalls. Dr. Wahr says it's imperative to foster a
non-punitive, real-time error reporting system, so you can quickly identify
breakdowns in medication administration processes that set your
providers up to fail. For example, use "tall man" lettering to differentiate
similarly spelled medications and store drugs with look-alike and sound-
alike names in non-adjacent bins in the anesthesia tray.
6. Standardize. Standardize anesthesia drug trays in every OR, says
Dr. Wahr. She suggests you develop a basic tray that's used during
every case, and add ancillary trays for specific surgeries that require
additional medications. Prefilled, premixed medications eliminate
having concentrated medications, or drugs that need to be diluted, in
the anesthesia cart and help ensure the right dose of the right medica-
tion is administered.
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SURGICAL
ERRORS