Anesthesiology has been a leader in adopting safety improvements, such as human factors engineering and critical incident analysis. This commentary suggests that anesthesiology focus on enhancing safety of high-alert intravenous medication use. The authors argue that the current focus on individual practice vigilance be expanded to include an emphasis on systems design to reduce medication errors.

Medication errors represent a significant source of harm to patients. In this prospective study, researchers created a template to standardize the organization of medications within the anesthesia workspace. Although implementation of the template led to a decrease in anesthesia medication errors, there was no change in errors resulting in patient harm.

Checklists are considered a valuable tool for improving patient care, but they can be difficult to use reliably. This commentary recommends strategies to improve checklists to reduce the burden on providers, including working to enhance device and software operability and develop algorithms to synthesize incoming data.