Standardizing anesthesia medication drawers using human factors and quality assurance methods

Abstract

Purpose In Calgary, each of the three acute-care adult hospitals had different anesthetic medication carts with their own type and layout of anesthetic medications. A number of anesthesiologists moved among the different sites, increasing the potential for medication errors. The objective of this study was to identify the anesthetic medications to include and to determine how they should be grouped and positioned in a standardized anesthesia medication cart drawer. Methods A standardized list of medications was established. Next, the anesthesia medication cart drawer was filled and photographed, and a jigsaw puzzle was made from the photograph. Anesthesiologists and anesthesia assistants arranged the jigsaw pieces into an ideal drawer. Participants verbalized their rationale for the position of each puzzle piece. Results were collated and analyzed. A mock drawer was developed and reviewed by department members, and minor modifications were made. Results A final standardized medication drawer (content and positioning) was developed over 30 months, with agreement from anesthesiologists (n = 12) and anesthesia assistants (n = 3) at the three hospitals. Guidelines for placing each medication in the drawer included grouping them according to order of use, frequency of use, similarity of action, severity of harm from misuse, and lack of similar appearance. A finalized template was used for a standardized drawer and installed in every operating room of the three hospitals. Conclusion Implementation of the standardized medication drawer is expected to reduce the likelihood of medication errors. Future research should include testing the clinical implications of this standardization and applying the methodology to other areas. A survey of Canadian anesthesiologists showed that 85% of participants had made at least one medication-related error or close call. Résumé1 Most frequently, these errors involved administering muscle relaxants rather than reversal agents, typically as a result of misidentified ampoules and vials or 'syringe swaps'. Also, survey respondents identified incorrectly stocked medications as one of the contributing factors. Almost two decades earlier, Currie et al. found a similar pattern of results in voluntarily submitted incident reports, and they suggested that erroneously injected medications were frequently administered from a correctly coded or labelled syringe (63% of the time).2 Moreover, these authors noted that one-fifth of ampoule selection errors occurred because the cue to select the 'correct' ampoule was its location. Once selected, the likelihood of detecting the 'incorrect' medication before it was administered was relatively low (42%).Not standardizing the location of medications can contribute to the increased likelihood of an anesthesiologist selecting the incorrect medication or another individual stocking the incorrect medication. Also, inconsistently placing medications contributes to inefficiency, for instance, anesthesiologists and other healthcare providers must spend ti...

Improving Medication Management Through the Redesign of the Hospital Code Cart Medication Drawer

“…Agarwal et al (2005) conducted a study on pediatric code carts and found that having medications systematically organized (i.e., designed to facilitate their identification, use, and replacement) reduced medication retrieval times when compared to baseline drawers. Schultz et al (2010) collected feedback from relevant health care personnel and determined standardization, grouping of like medications, and organizing based on frequency of use were the most important factors to consider during code cart redesign; however, no formal testing was conducted. Last, it has been concluded that humans' cognitive architecture consists of a limited working memory (Paas, Tuoviinen, Tabbers, & Van Gerven, 2003), which adds to the importance of these code cart organizational improvements since a well-organized code cart can reduce load on working memory.…”

Anesthesia Workspace Cleanliness and Safety: Implementation of a Novel Syringe Bracket Using 3D Printing Techniques

“…Medication errors are the single most common cause of malpractice cases against anesthesiologists in Canada and account for approximately two-thirds of all damages awarded [20]. Subsequent efforts to standardize labeling and organization of medication carts [21] address the risk of mistaken or mis-stocked medication vials. However, in a survey of Canadian Anesthesiologists' Society members, the majority of medication errors were attributed to “syringe swaps” (60%), rather than in misidentification (39%) or mis-stocking (18%) of ampoules/vials [22].…”

Top 10 Patient Safety Issues: What More Can We Do?

“…19 What More Can We Do? 21 We also need to standardize the doses that are used for medications such as epinephrine in irrigation and tumescent solutions. First, we should separate medications for adults, pediatric patients, and neonates.…”

“…Other recommendations include n reviewing and revising code carts, which entails n stocking a separate pediatric code cart, n color coding the different drawers based on child size, 20 and n stocking a separate neonatal medication box for the code cart if neonates are treated in the facility; n providing medication reference sheets with IV titration dosing guides for all medications in all concentrations available; and n standardizing medication trays within the facility, including; n stocking the separate trays with appropriate doses for the patient receiving care and n standardizing medication trays across facilities in the geographical area to provide consistency for anesthesia professionals who work in more than one setting. 21 We also need to standardize the doses that are used for medications such as epinephrine in irrigation and tumescent solutions. When pharmacy personnel are available, they should mix medications under a hood if the medication is intended for use on the sterile field.…”