NEWSLETTER The Official Journal of the Anesthesia Patient Safety Foundation www.apsf.org ® Volume 25, No. 1, 1-20 Circulation 84,122 Spring 2010 See “Medication Safety,” Page 3 • Ready-to-use syringes and infusions should have standardized fully compliant machine– readable labels. Technology • Every anesthetizing location should have a mecha- nism to identify medications before drawing up or administering them (bar code reader) and a mecha- nism to provide feedback, decision support, and documentation (automated information system). Pharmacy/Prefilled/Premixed • Routine provider-prepared medications should be discontinued whenever possible. • Clinical pharmacists should be part of the periop- erative/operating room team. • Standardized pre-prepared medication kits by case type should be used whenever possible. Culture • Establish a “just culture” for reporting errors (includ- ing near misses) and discussion of lessons learned. • Establish a culture of education, understanding, and accountability via a required curriculum, CME/CE, and dissemination of dramatic stories in the APSF Newsletter and educational videos. • Establish a culture of cooperation and recognition of the benefits of STPC within and between Overview On January 26, 2010, the Anesthesia Patient Safety Foundation (APSF) convened a consensus conference of 100 stakeholders from many different backgrounds to develop new strategies for “predictable prompt improvement” of medication safety in the operating room. The proposed new paradigm to reduce medication errors causing harm to patients in the operating room is based on Standardization, Technology, Pharmacy/Prefilled/Premixed, and Culture (STPC). This new paradigm goes far beyond the important but traditional emphasis on medication label format and the admonition to “always read the label.” Small group sessions on each of the 4 elements of the new paradigm (STPC) debated and formulated specific recommendations that were organized and prioritized by all the attendees. The resulting consensus recommendations include: Standardization • High alert drugs (such as phenylephrine and epinephrine) should be available in standardized concentrations/diluents prepared by pharmacy in a ready-to-use (bolus or infusion) form that is appropriate for both adult and pediatric patients. Infusions should be delivered by an electronically controlled smart device containing a drug library. institutions, professional organizations, and accredi- tation agencies. It was agreed that anesthesia professionals will likely surrender some of their “independence,” adapting their medication preparation and delivery preferences and habits into more standardized prac- tice patterns (involving guidelines and checklists), utilizing more standardized and premixed medica- tions (input and supply by pharmacy services), and relying more on technology. Facilities and their administrators that are sensitive to the economic value of safety (return on investment) are critical to the effort, for both moral support to do the right thing and for provision of financial support for change. Practitioners in the operating room may take some convincing, but culture and patient safety can improve and medication errors causing morbidity and mortality can be dramatically reduced—just as happened with intraoperative monitoring years ago. CONFERENCE REPORT Persistent reports of medication accidents occur- ring in the operating room with resultant harm or potential harm to patients prompted the APSF to con- vene a consensus conference of 100 stakeholders from many different backgrounds on January 26, 2010, in APSF Hosts Medication Safety Conference Consensus Group Defines Challenges and Opportunities for Improved Practice by John H. Eichhorn, MD — AN EXCERPT REPRINTED WITH THE PERMISSION OF THE ANESTHESIA PATIENT SAFETY FOUNDATION — — AN EXCERPT REPRINTED WITH THE PERMISSION OF THE ANESTHESIA PATIENT SAFETY FOUNDATION —
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NEWSLETTERThe Official Journal of the Anesthesia Patient Safety Foundation
www.apsf.org
®
Volume 25, No. 1, 1-20 Circulation 84,122 Spring 2010
Foundation(APSF)convenedaconsensusconferenceof100stakeholdersfrommanydifferentbackgroundstodevelopnewstrategiesfor“predictablepromptimprovement”ofmedicationsafetyintheoperatingroom. The proposed new paradigm to reducemedicationerrorscausingharmtopatientsintheoperating room is based on Standardization, Technology, Pharmacy/Prefilled/Premixed, and Culture (STPC).Thisnewparadigmgoesfarbeyondtheimportantbuttraditionalemphasisonmedicationlabelformatandtheadmonitionto“alwaysreadthelabel.”Smallgroupsessionsoneachofthe4elementsofthenewparadigm(STPC)debatedandformulatedspecificrecommendationsthatwereorganizedandprioritized by all the attendees. The resultingconsensusrecommendationsinclude:
Multiplereportsandanalysesof“syringeswaps”andincorrectsyringelabels,look-alikelabels,look-alikemedicationvialsandampoules,incorrectinjec-tionsites(intoepiduralorarterialcatheters),andinfusionpumpconfusionorprogrammingerrorshaveappearedintheAnesthesia Patient Safety Foundation Newsletterandotherjournalsinrecentyears.1-3APSFconductedits2008AnnualWorkshopon“InnovationsinMedicationSafetyintheOperatingRoom,”withthereportofthismeetingbeingpublishedintheWinter2008-09APSF Newsletter.3Otherreviewsandeditorialshaveconsidereddistinctivelabelformatformedicationcontainersandsyringes,uniformdruglabelingstandards,andamoreuniversalroleofphar-macyservices.4-7Whileallthosearerelevant,little,ifanything,haschanged.Operatingroommedicationerrorscontinuetooccur,manywithsignificantmor-bidityand/ormortality.Anesthesiaprofessionalsintheoperatingroomhaveauniqueroleandresponsi-bilityinthattheyaretheonlymedicalpersonnelwhoprescribe,secure,prepare,administer,anddocumentmedications—aprocessthatcantakeupto41steps—usuallywithinaveryshorttimeinterval.2Inadditionthesestepsoccurinrealtime,autonomously,ofteninadistractingenvironment,andtypicallywithoutstan-dardizedprotocols.
Becausepasteffortstoimprovemedicationsafetyhavenotbeenparticularlysuccessful,thepurposeofthis conference was to develop new ideas andapproaches.ReferencewasmadetothequotationpopularlyattributedtoEinsteinthatthedefinitionofinsanityisdoingthesamethingoverandoverandexpectingadifferentresult.Theconferencetitlewas“MedicationSafetyintheOperatingRoom:Time for a New Paradigm.”Thethemeofthe“newparadigm”had 4 elements: Standardization, Technology, Pharmacy/Prefilled/Premixed and Culture (STPC),representinganew4-prongedapproach to thepersistentproblemsofmedicationsafety in theoperatingroom.
Robert K. Stoelting, MD,APSFpresident,servedastheoverallmoderatorfortheintense1-dayconfer-ence.HeopenedwiththevideoBeyond Blame, pro-ducedin1997anddistributedbytheInstituteforSafeMedicationPractices.Thevideocontainsinterviewswithananesthesiologist,anICUnurse,andapharma-cist,eachofwhomwasinvolvedwithafatalmedica-tionerror.Thevideostresses,“Itcouldhappentoanyone.”Despitethepassageof13yearstheissuesinthevideoremainedhighlyrelevant in2010.Dr.Stoeltingalsonotedtheoften-citedstatisticthatthereis1significantanestheticmedicationerrorinevery133anestheticsadministeredand,ofthoseerrors,1outof250isfatal.1Thistranslatestonearly1000deathsayearintheUnitedStates.Acknowledgingthe
Dr.Stoeltingintroducedanovelformatconsistingof20invitedspeakersfromwidelyvaryingdisciplinesandbackgrounds(clinicalanesthesia,research[includ-inghumanfactors],surgery,operatingroomnursing,administration,pharmacy,regulators,andthepharma-ceutical/medicationdeviceindustry).Eachspeakerhada15-minutetimeslot—butallwiththesametopic:“Time for a New Paradigm: Standardization, Technology, Pharmacy, Culture.”Eachwasaskedtoaddressrelevantelementsoftheparadigmfromtheirspecialperspec-tive.Followingthese20presentationstheentireassem-blywasdividedbyinterestandexpertiseinto4smallgroupbreakoutsessions,oneforeachcomponentoftheSTPCparadigm.Theassignmenttoeachgroupwastogeneratealistofactionableitemsinorderofimpactthat,ifimplemented,wouldproduce“predictablepromptimprovement”inoperatingroommedicationsafety.Afinalcombinedsessionsetthestagefordevel-opmentofconsensusstatementsastheprimaryprod-uctoftheconference.
World Class ExpertsThekeynotespeakerwasAlan F. Merry, MBChB,
headofanesthesiologyattheUniversityofAuckland,NewZealand,formerchairofthePatientSafetyCommittee of the World Federated Societies ofAnesthesiologists,andfounderofSaferSleep,LLC,acompany thatprovides technology intended toincreaseanestheticmedicationsafety.Hecitedtherecent ly adopted “Guide l ines for the Sa feAdministrationofInjectableDrugsinAnaesthesia”fromtheAustralianandNewZealandCollegeofAnaesthetists that focus on standardization ofmedication administration as opposed to thet r a d i t i o n a l a p p ro a c h o f e a c h p r a c t i t i o n e rindependentlymakingthesedecisions.HealsonotedthattheInternationalStandardsOrganizationmostrecentpublicationregardingcontentofadhesivesyringelabelsincludestheclassofdrug(“inductionagent,”“musclerelaxant,”)aswellasthedrugnamealongwithspacetowritetheconcentrationanddateand, also, a bar code. Another component ofstandardizationisintheanesthesiaworkspace,inthathesuggestsauniformarrangementofmedications,syringes,emptydrugcontainersforeverycasebyeveryprovider.Becauseofhumannature,errorswilloccuratpointsinthedrugadministrationprocess,andDr.Merrysuggestedorientationtowardmanagingpredictableerrorsratherthanthefutileattempttoeliminateallerrors.Havingasatellitepharmacyinthe
operating roomarea isa forwardstep.Havingmedicationcontainerscomeintotheoperatingroomwithattachedpeel-offdetailedlabelsreadytogoonthesyringeisanotherrelatedstep.Applicationoftheincreasinglyeffective“checklistmentality,”especiallyifasecondpersonoradevicesuchasabar-codereaderwithspokenvoicerepetitionofthenamechecksthedrugabouttobegiven,wasemphasized.Finally,froma“culture”perspective,henotedthatanesthesiaprofessionalsmayexhibitproblemswithdenialandalsobelievetheyareallaboveaverage,butthatthesefeaturesmustbeovercomewithagenuinereportingsystemthatrecognizesandrecordserrors,enablinganalysisandsubsequentsystemmodificationtopreventrepetition.
Medication Safety Conference Develops New Strategies“Medication Safety,” From Page 1
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Donald E. Martin, MD
Systematicimprovementofthehumanperfor-mancerequiredinanestheticdrugadministrationwasthethemeofDonald E. Martin, MD,fromPennStateCollegeofMedicine.Theusualhumanfactorsassoci-atedwithaccidents,ledbyinattention(butalsofail-uresofmemory,knowledge,ormotivation),areassociatedwithdrugerrorsintheoperatingroom.Hepresentedananalysisofthe41stepsinvolvedinfirst-timeadministrationofadrugduringananestheticandnoted36wereautomaticbehaviorwithmusclememoryand5requiredconsciousattention,deci-sions,andjudgment—asetupforinattentiontothe5criticalsteps.Waystohelpdirectattentionbytheanesthesiaprofessionaltothekeypartsofdrugadministrationwerepresented,includingbothergo-nomicsoftheanesthesiaworkspace(arecurrentpointfrommanypresentations)andlargerandlouderstim-ulitotargetmultiplesenses.Dr.Martinmadeanalo-giestofunctioninthecockpitofacommercialairliner,particularlynotingthebeneficialuseofchecklistsandalsotheconceptofthe“cultureofsafety”whereindi-vidualautonomyofactionissurrenderedandthepre-scribed“standardoperatingprocedure”istheonlyacceptablebehavior.Heendedwithapleatoinvolvetheentireoperatingroomteamin theeffort toimprovemedicationsafety.
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Robert A. Caplan, MD,memberoftheAPSFExecutiveCommitteeandmedicaldirectorofQualityatVirginiaMasoninSeattle,inaparticularlypoignantpresentation,emphasizedtheimportanceofthe“cul-ture”ofmedicationlabelingbyrecountingatragicaccidentthatoccurredinhisorganizationin2004.Apatientwhowasundergoinganinterventionalradiol-ogyprocedureaccidentlyreceivedafatalinjectionofchlorhexidine(aprepsolution)insteadofcontrastdyebecausebothsolutionswereinsimilar,unlabeledcon-tainersontheproceduretable.Asaresultofthisevent,theleadershipandsafetyteamsatVirginiaMasonmadeseveralkeydiscoveriesabouttheexisting“cul-ture”ofmedicationlabeling.First,medicationlabel-ingwasregardedasdesirablebutnotmandatory.Second,thestrongestmotivationfornotlabelingwasconvenience.Andthird,itwasnotpossibletojustifynon-labelingbehaviorwithclinical,ergonomic,oreco-nomicarguments.Asaresult,VirginiaMasondevel-opedanexplicit,standardizedprocessformedicationlabeling.Theprocessisnowusedthroughouttheorganization.Dr.Caplannotedthatthiseventanditsassociatedlessonshaveacceleratedtheimplementa-tionofotherrelatedsafetystrategies.
Roots of the ProblemAdifferentaspectofthequestionwasaddressed
AdifferenttakeonhumanfactorsengineeringwasprovidedbyJohn W. Gosbee, MD,oftheUniversityofMichiganwhopresentedanelaborate“equation”describingoperatingroommedicationerrors,inwhichtheprobabilityofconfusionwastheproductof6fac-tors:“soundalike,lookalike,locationexpectation,locationtrust,workflowexpectation,andworkflowtrust.”Heanalyzedandprovidedexamplesofeachfactorintheanesthesiaworkstationenvironmentinatypicaloperatingroom.Moreemphasiscameonthecontextofmedicationuseintheworkareathanonlabelingitself.Hesuggestedthatverysimplefactorssuchasstrictstandardizationoftheanesthesiaworkspace,especiallythelocationofstoredmedications,wouldhelpimprovesafetynowwhilemorecomplextechnologicsolutionsinvolvingbarcodes,readers,andcomputerizedrecordsaredevelopedandrigorouslytestedforefficacy.
AsurgicalperspectiveonORmedicationsafetywasofferedbyamemberof theAPSFBoardofDirectors,William P. Schecter, MD,fromUCSFandSanFranciscoGeneralHospital.Hefunctionallypro-videda“morbidityandmortalityconference”basedonoperatingroommedicationerrorshehadwit-nessedovertheyears.Attheoutset,henotedtheten-sionandcomplexinteractionbetweenhumanerrorandsystemfailureandhowthiscouldrelateto
“Medication Safety,” From Preceding Page
Maria Magro, CRNA
Experts Offer Insight into Causes of Errors
Jerry A. Cohen, MD
See “Medication Safety,” Next Page
Jerry A. Cohen, MD,firstvice-presidentoftheAmericanSocietyofAnesthesiologistsandfromtheUniversityofFlorida,statedthatfragmentationoftheapproachtomedicationsafetyproblemsisitselfasig-nificantproblem.Hemaintained,theSwiss-cheesemodelofhumanerrorandaccidentsnotwithstanding,thatattemptingtoisolaterootcausesobscurescom-plexinteractivepathways(systemfunction)thatleadtoerrors.Hecitedahostofindividualfactorsthatcancontributetomedicationerrors,particularlyfailuretostandardizetheoperatingroomenvironment,espe-ciallytheanesthesiaworkarea,whichleadstochaosanddistractionandanequallylonglistofbarrierstoimprovement,especiallyresistancetochecklists,com-municationsilos,andproductionpressure.Dr.Cohensuggestedthatwidespreadstandardizationandalsotheuseofpharmacy-preparedbarcodedmedications
Robert A. Caplan, MD
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TheInstituteforSafeMedicationPractices(ISMP)wasrepresentedbyAllen J. Vaida, PharmD,itsexecutivevicepresident.TheISMPfocusisonthesystemcausesofmedicationerrorsandresultingsystemchangesthatmustbeimplementedalongwitheducationtopreventrecurringpatterns.Dr.Vaidastressedemployinganopenenvironmentofsharingerrors in terna l ly and ex terna l ly to sa fe tyorganizationsforlearning,sharing,andbringingaboutchange.Henotedrelativelypoorcompliancewithlabelingpoliciesandproceduresduringdrugadministrationandalsoshowedmanyexamplesofstriking look-alike drug vials (and noted thedisproportionatelygreatnumberof look-alikeaccidents involvingmusclerelaxants).Healsostressedthatclinicians(workingtoachieveconsensuswith pharmacists and manufacturers) need toestablishandaccepta relatively limitedsetofstandardizedconcentrationsfordrugs.Ata2008nationalconsensusconferenceon thesafetyofintravenousdrugdeliverysystems,therewasaclearpreferenceformanufacturer-preparedcompletelyready-to-useIVmedicationinallsettings,althoughincreasedcostandpotentialinapplicability(suchasforseldom-usedbutnecessarydrugsintheanesthesiaoperatingroomarmamentarium)aredrawbacksofthatapproachifstandardizationisnotagreedupon.Dr.Vaidaalsonotedaclearpreferenceforsatellitepharmaciesinoperatingroomsuitesbutnotedthatwhenthatisnotpossible,theremustbeorganizedinvolvementfrompharmacyforanesthesiaservicesintheoperatingroomtosupportmedicationsafety.
Pharmacy PracticesPhilip J. Schneider, RPh,associatedeanofthe
Patricia C. Kienle, RPh,anindustryrepresenta-tiveholdingthepositionofdirector,AccreditationandMedicationSafetyforCardinalHealth,Inc.,stressedtheneedforstandardizationofallthekeyfunctionsintheverycomplextaskofanestheticmedi-cationadministrationintheoperatingroom,illustrat-ing her point with multiple photos of actualanesthesiaworkstationswithwhatseemedlikequasi-chaotichodgepodgesofmedicationstorageandadministration.However,sheassertedthatcolor-codingofmedicationcontainersmaynotbeahelpandmayactuallybeadetrimentinsomecases.ShealsonotedtheUSPpracticestandardforsterilityof“compoundedpreparations”andsuggestedthatthetraditional100mlbagofphenylephrinemadeupfromanampoulebymanyanesthesiaprofessionalsatthestartofaworkdaydoesnotmeetthatstandard.
Andrew J. Donnelly, PharmD, director ofPharmacyattheUniversityofIllinoisMedicalCenteratChicago,emphasizedthatcostofmedicationsandassociatedpersonnelisahugeissuetodayforhealthcareinstitutionsfacingbudgetconstraints.Further,healsonotedthattheuniquemedicationuseprocessforanesthesia in theoperating roomhasminimalinvolvementofpharmacyandlacksthenormalchecksandbalances.Headvocatedforamuchmorerobustpresenceofpharmacyserviceintheoperatingroom,evenwithoutasatellitepharmacy,inordertogainthebenefitofateamapproachwiththepharma-cistfunctionallyasthe“PerioperativeMedicationSafetyOfficer”inculcatingacultureofsafety.Thiswouldinvolveallergyverification,disseminationofdruginformation,formularymanagement,facilita-tion(shortages;look-alike,sound-alike),qualityimprovementprojects,andevenresearchprojects.Dr.Donnellycitedsurveyresearchshowingthat“ready-to-use”medicationsarestronglypreferredbypracti-tioners,leadingtotheideathatcollaborationbetweenanesthesiaprofessionalsandtheirpharmacistsshouldleadtoconsensusonwhichmedicationsareprovidedinready-to-useforminthatoperatingroom.Healsofavoredstandardizationofmedicationsandconcentrations,throughoutaninstitutionandevenacrosstheentireindustry.Hecommentedonthelargenumberandquantityofmedicationsintheusualanesthesiaworkstation,suggestingthisisoftenwastefulandpotentiallydangerouslyconfusing—thepreferablealternativebeinggreaterrelianceonandinteractionwithpharmacyservice,evenifitisanautomateddispensingmachineora“smartpump”foraready-to-useinfusionmedication.
Anotheradvocateforimprovingoperatingroommedicationsafetyby“teamingupforinno-vation”withpharmacistsandmakingthemanintegralpartoftheoperatingroomteamwasBona E. Benjamin, RPh,whoisdirectorofMedication-UseQualityImprovementfortheAmericanSocietyofHealth-SystemPharmacists,anorganizationthatrecentlyheldan“IVSafetySummit.”Shecitedsev-eralstudiesshowingthecostandoutcomebenefitsofpharmacistinvolvementinmedicationadministra-tion,includingspecificallyonelarge2007studyofsurgicalpatientsshowingthosewithoutpharmacist-managedantimicrobialprophylaxishad52%higherdeathratesfromsurgicalsiteinfections,10%longerlengthofstay,and7%higherdrugcharges.Noting
Pharmacists Weigh in on Medication Error Prevention
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Bona E. Benjamin, RPh
“Medication Safety,” From Preceding Page
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syringelabelalsohasabarcodethatisread(withvisualandaudibleconfirmation)andrecordedbytheassociatedcomputerizedanesthesiaautomatedrecord/informationmanagementsystem(AIMS).ThissyringebarcodeiseasilyintegratedwithAIMSsothatatthetimeofadministration,thebarcodeisscannedtoconfirmthedrugnameandconcentration,patientallergies,ifthesyringehasexpired,andifthesyringehasalreadybeenusedforanotherpatient.Dr.Levinedetailedhowthissystemcanalsobeinte-gratedasthesafetysystemforseamlessusewithready-to-useprefilledsyringes.Henotedthatinhisinstitutionwheresomeroomshavethetechnologyandothersdonot,practitionerswhohaveworkedwiththesystemalwaysrequesttobeassignedtoroomswiththecomputerizedsystem.Heconcludedwith thebelief that technologycombinedwithincreasedpharmacyserviceswillleadtobest(safest)operatingroommedicationpractices.
Industry PerspectiveTodd N. Jones, RN, directorofMarketing,
thattheoperatingroomisthemostmedication-inten-siveareaofthehospital,Ms.Benjaminsuggestedthatnowisagreatopportunitytocoordinatewhatanes-thesiaprofessionalswant(medicationsreadytouse,readilyavailable,andeasytostore,identify,adminis-ter)withwhatpharmacistswant(effectiveevidence-basedprocessesthatareefficient,safe,andcompliantwithregulatoryandaccreditationstandardsandthatpromotesafetythroughstandardization,bestprac-tices,security,andcontrol).Sheconcludedwithalistofbenefitspharmacistscanbringtoenhancemedica-tionsafetyintheoperatingroom:formularymanage-ment;developmentofevidence-basedstandardprotocols;reviewofplanned/orderedmedicationsforpotentialproblems;analysisofdrugusepatternstoidentifyopportunitiesforimprovement;participa-tioninemergenciesandmaintenanceofantidotesup-plies; support of compliance with regulatory,accreditation,andorganizationalrules;educationonmedications,safetyprograms,anderrorprevention;andateamcultureapproach.
adaptedtooperatingroommedicationsafetycon-cernswasofferedbyBruce D. Spiess, MD,fromVirginiaCommonwealthUniversityandalsochairoft h e F O C U S g r o u p ( F l a w l e s s O p e r a t i v eCardiovascularUnifiedSystems)oftheSocietyofCardiovascularAnesthesiologists(SCA).SCAisengagedinacomprehensivelongitudinalprojecttostudyeveryconceivableaspectofcardiovascularanesthesiapracticeutilizingreal-timeobservationaswellasliteraturereviewtodeterminewhyerrorsoccuranddevelopbestpractices(withchecklists)emphasizingsystems,humanfactors,andtheteamapproachtopreventthoseerrors.Aparallelprojectforoperatingroommedicationsafetyimprovementwasproposedthatwouldutilizethesamedesign.
Amoredirectexamplewaspresentedby Wilton C. Levine, MD,clinicaldirector,DepartmentofAnesthesia,CriticalCareandPainMedicineattheMassachusettsGeneralHospital.Havingparticipatedinanexhaustivestudyofoperatingroommedicationpractices,hebecameoneofthedevelopersofananes-thesiamedicationmanagementsystemthatemploysasmallprinterineachanesthesiaworkstationandareaderthatidentifiesamedicationbythebarcodeonitscontainerandprintsacorrespondingfullycompli-antandwaterproofsyringelabelinrealtime(“SmartLabel”).Hesuggesteditisimpracticaltohave100%“ready-to-use”pre-filledsyringesforallmedicationsanesthesiaprofessionalsuseinallanesthetizingloca-tionsandthattheautomatedlabelprinteristheappli-cationofatechnologyinplaceofhavingasecondpersoncheckandverifyallmedicationsdrawnupandadministeredbyananesthesiaprofessional.The
Mary Baker, PharmD,medicalmanager,GlobalMedicalAffairsforHospira,Inc.,addressedthechal-lengesofinjectabledruglabeling.Shesuggestedthatcolor-codinghasdrawbacksandthateffortsshouldbedirectedatmakingtheinformationintheprintingmoreeffectivelycommunicatedbythelabel.Barcodingisessentialandstandardizationoflabelingpoliciesiscritical,sheemphasized.
Timothy W. Vanderveen, PharmD,vicepresi-dent,CenterforSafetyandClinicalExcellenceforCareFusionCorp.,alsostressedtheuniquechallengeoftotalmedicationmanagementbyasingleanesthe-siaprofessionalintheoperatingroomwhousuallyreliesonpersonalhabitsandexperiencetoexecutetheprocess.RemindersofthewidelypublicizedIndianadeathsfromheparindosageerrorsinnew-bornsandthestoryofanOhiopharmacistsentencedtoprisonafterthedeathofachildduetoacom-poundingerrorservedtoemphasize thegreatresponsibilityinvolvedinpreparingandadminister-ingIVmedications.Hesuggestedthatbarcodingtechnologyandautomateddrugdispensingcabinetsineachoperatingroomwouldhelporganizeandstandardizemedicationpractice,promotingmedica-tionsafety.Henotedtheaddedbenefitofsuchacom-puterizedsystemfortrackingcontrolledmedicationsandmaintainingvigilanceforanypotentialdrugdiversionbycaregivers.Anotherbeneficialtechnol-ogywithbeneficialsafetyimplicationsissmartinfu-sion pumps that decrease chances for dosecalculationerrors,smoothtransitionstoandfromtheoperatingroomforpatientsoncriticalinfusions,andthatperhapssomedayintheUnitedStateswillbeutilizedtoadministertarget-controlledinfusions.
ThefinalpodiumpresentationwasfromMark W. Vaughan,globalproductdirector,HospitalInfusion,SmithsMedicalNorthAmerica,whoadvo-catedforsmartinfusionpumpsandtechnologyuti-lizing standardized drug concentrations thatsimplifythefunctionoftheinfusionpumps(whichsoonwillbewireless).Traditionalpumpsarepronetoprogrammingerrorsthatcouldendangerpatients.Healsopromoteduniqueconnectorsthatwouldpre-ventaccidentalcrossinjectionsamongIV,epidural,andenteralinfusionlines.Withtheadmonitionthat“pharmacyisyourfriend,”heagainstressedstan-dardizationofmedicationpreparationsaskeytoimprovingORmedicationsafety.
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Industry Advises on Prevention of Medication Mistakes
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Figure 1. Look-alike medications; left medication is dexamethasone and right vial is glycopyrrolate.
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Small Groups, Big AssignmentsPredictably,eachofthe4groupbreakoutses-
sions:Standardization, Technology, Pharmacy/Prefilled/Premixed, and Culture,generatedintensedebate.Therewasaspecificassignmenttogenerateupto3primaryactionablerecommendationsthatcouldproduce“predictablepromptimprovement”inoperatingroommedicationsafety.Therewasalsotherequirementtobalancetheoftencontradictorycon-siderationsoftheclearlyidealtop-prioritybeneficialmeasuresvs.therealisticpracticalityofpotentialforimplementationintheshort-termfuture.Thus,the
TheStandardizationGroup,ledbyPatricia A. Kapur, MD,APSFExecutiveCommitteemember,consideredwhatdegreeofstandardizationwouldbeachievableforwhichcomponentsoftheoperatingroommedicationprocessandhowthatcouldbeaccomplished.TheTechnologyGroup,ledbyGeorge A. Shapiro,APSFexecutivevicepresident,eventu-allydecidedtoleavetheissueofconfigurationofmedicationcontainerstotheStandardizationGroupandfocusonhardwareandsoftwarethatcouldpre-ventdrugerrors.ThePharmacyGroup,ledbySorin J. Brull, MD,chairoftheAPSFScientificEvaluation
Committee,struggledwiththebalanceofrolesbetweentheanesthesiaprofessionalintheoperatingroominrealtimeandtherelatedsupportingpharma-cistasfarasmaximizingsafetyofmedicationproce-dures.TheCultureGroup,ledbyRobert C. Morell, MD,editoroftheAPSF Newsletter,debatedwhatwouldbethebesttargetmindsettopromoteoperat-ingroommedicationsafetyandthenhowbesttoachievethatgoal.
Becausethecentralpremiseofthisconferencefocusedondevelopingmeasuresaboveandbeyondthebasicsofmedicationlabelformatthathavebeen discussed for years, it was nonethelessemphasizedinthefinalconsensus-developmentsessionthateveryoneinvolvedmustneverlosesightofthestartingfoundationconceptthattheremustbefullycompliantlabelingofallmedicationcontainersandsyringesusedintheoperatingroomasthenucleusofmedicationsafetyefforts(seealsothe American Society of Anesthesiologists ’“StatementontheLabelingofPharmaceuticalsforUseinAnesthesiology”).3-5However,therole,utility,andfeasibilityofcolorcodingrequiresadditionalstudyandconsensusbuilding.
Due to conceptual overlap some ideas formedicationsafety“actionitems”werecombinedortransferred.Theresultinglistoftheactionitems(practicalrecommendationsfor“predictablepromptimprovement”inoperatingroommedicationsafetyintheimmediateshort-term)ispresentedinTable1.
Today,noanesthesiaprofessionalbeginsananes-theticwithoutcomplyingwithuniversallyacceptedapproachestointraoperativemonitoring.APSFsup-portsasimilarapproachformedicationsafetyintheoperating room that includes theparadigmofStandardization, Technology, Pharmacy/Prefilled/Premixed and Culture (STPC).Thehopeisthischangewillresultinadramaticreductioninthestill-persistentmedicationerrors,whichresultinpatientmorbidityandmortality.
John H. Eichhorn, MD, Professor of Anesthesiology at the University of Kentucky, served as the first editor of the APSFNewsletter beginning with its initial publication in March 1986. He remained as editor until 2002 and contin-ues to serve on the Editorial Board and is a consultant to the APSF Executive Committee.
References
1. Stabile M, Webster CS, Merry AF. Medicationadministrationinanesthesia:Timeforaparadigmshift.APSF Newsletter 2007;22(3):44-6.