Perioperative medication errors: uncovering risk from behind the drapes.
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. 2018;15(4):1-17.