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- Communication Improvement 3
- Culture of Safety 1
- Education and Training 1
- Human Factors Engineering 4
- Quality Improvement Strategies 1
- Technologic Approaches 3
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Errors/Preventable Adverse Drug Events 5
- Psychological and Social Complications 1
- Surgical Complications 2
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Cases & Commentaries
- Web M&M
Audrey Lyndon, PhD, RN, and Stephanie Lim, MD; June 2019
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
Journal Article > Study
Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.
Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.
A comprehensive quality improvement intervention resulted in a significant reduction in adverse drug events due to opioid pain medications, particularly in the immediate postoperative period.
Journal Article > Study
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.
Bowdle TA, Jelacic S, Nair B, et al. Br J Anaesth. 2018;121:1338-1345.
This pre–post study of errors in anesthesia compared self-reported errors before and after implementation of a medication safety bundle that included smart infusion devices and barcode medication administration. Wrong-medication errors declined after barcoding was introduced, consistent with prior studies.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
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.
Journal Article > Review
Mackay E, Jennings J, Webber S. BJA Education. 2019;19:151-157.
Human factors affect medication delivery in the operating room. This review highlights the role of the anesthesiologist in safe medication administration and recommends strategies to reduce opportunities for error at each stage of medication administration, such as preoperative time-outs, preparation of medicines with color-coded syringe labels, patient identification prior to medication administration, and review of medications at handovers after administration.