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This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the role of standardized processes, such as checklists, to ensure medication safety.
Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.
This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.
Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765