Medication Handling Errors in the OR

Medication handling errors are a major cause of morbidity and mortality in hospitals, especially in the operating room (OR). The discipline of anesthesiology involves the delivery of multiple potent drugs, often given in rapid succession during high-acuity situations. The specialty is unique, as it is responsible for the direct preparation, dosing, and delivery of medications to patients by an anesthesiologist, certified registered nurse anesthetist (CRNA), and/or anesthesia assistant (AA) (1).

Medication handling errors in the OR are not new, and unfortunately, they continue to occur despite being studied and reported since the earliest days of anesthesia. Thirty years ago, Cooper and colleagues published a landmark study in anesthesia when they applied the model of critical incident reporting, a concept that originated in aviation, to the study of perioperative safety (2). Critical incident analyses of major errors in anesthesia management revealed that human error was involved in nearly 70% of all events. One-fifth of all events discovered in this study were related to medication errors; yet of the incidents attributed to human error, approximately one-third were related to medications. Such events included inadvertent syringe substitutions, drug overdoses (syringe or vaporizer), and wrong choice of drugs. These findings began to bring awareness of patient safety to the fields of medicine and anesthesia (2). A study by Webster and colleagues, of nearly 8000 instances of delivered anesthetics, reveals that the two largest categories of medication handling errors are incorrect dosing (20%) and accidental substitutions (20%) (3). Sixty-three percent (63%) of all errors involved intravenous boluses. Among the intravenous bolus substitution errors, most occurred between different pharmacologic classes. These errors were implicated in subsequent negative outcomes, involving increased intraoperative awareness, prolonged mechanical ventilation, and transient physiologic effects requiring additional interventions. None of these reported errors resulted in death or permanent morbidity. More recent work, however, has approximated that 1 in every 250 drug errors is fatal (3).

In January 2010, the Anesthesia Patient Safety Foundation (APSF) issued consensus recommendations on perioperative medication safety (1). The APSF proposed a new paradigm built upon the traditional requirements of medication label formatting and an emphasis on the careful reading of labels. Their recommendations include a new paradigm of standardization, technology, pharmacy, and culture (SPTC) (1). Their first recommendation is that high alert drugs should be available in standardized concentrations prepared by pharmacies 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. Ready-to-use syringes and infusions should have standardized fully compliant machine-readable labels (1). Next, every anesthetizing location should have a mechanism to identify medications before drawing up or administering them (barcode reader) and a mechanism to provide feedback, decision support, and documentation (automated information system). Additionally, it is recommended that routine provider-prepared medications should be discontinued whenever possible. Clinical pharmacists should be part of the OR team. Standardized pre-prepared medication kits by case type should be used whenever possible (1)

Medication handling errors in the perioperative setting have been studied and reviewed, and anesthesiologists have a crucial role in developing safe drug delivery strategies. The standardization of medications, in conjunction with the implementation of technological solutions to provide real-time feedback is necessary for optimizing patient safety. The promotion of a culture of accountability and increased transparency is needed to encourage clinicians to report errors, so that further analysis and recommendations can be provided. The process of reporting in a formal and unbiased forum helps a clinician understand the specific nature of the error, and an opportunity is given to rectify systems-based factors that may have contributed.



1. Hanna GM, Levine WC. Medication safety in the perioperative setting. Anesthesiol Clin. 2011;29(1):135-144. doi:10.1016/j.anclin.2010.11.009

2. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984;60(1):34-42. doi:10.1097/00000542-198401000-00008

3. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001;29(5):494-500. doi:10.1177/0310057X0102900508