Improving Anesthesia Services – Build Processes to Reduce Medication Errors

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The 2 new Rs of anesthesia patient safety: Right Indication and Right Documentation

Medical practitioners are familiar with the 5 Rs of patient safety viz.

  • Right patient
  • Right drug
  • Right dose
  • Right concentration
  • Right time

However the rise of medication errors during procedures has necessitated the addition of 2 more…

  • Right indication, and
  • Right documentation

You can never be too careful in the operating room or even during an office-based procedure. A small mistake can lead to disastrous consequences. As errors in the preparation and administration of medication seem to be on the rise, the need for the “double check” has become supremely important. And anesthesia service providers are not exempt.

Here are some guidelines that will help reduce medication errors:

  • Proper process: Implement a proper process including efficient double check techniques and equipment that facilitates right indication and documentation.
  • Easy-to-read labeling: New and improved, easier-to-read standardized labeling, color and bar coding reduces chances of error significantly. Bar coding is also extremely helpful in improving documentation and billing.
  • Diligent reporting: Regular communication among anesthesia providers about medication used, techniques and procedures increases awareness of issues as well as vigilance.
  • Constant monitoring: There is no substitute for constant monitoring of a patient’s vitals and well-being for the slightest changes, to prevent small issues from assuming monumental proportions.

Medical Director – Quality and Staff Anesthesiologist at Virginia Mason Medical Center in Seattle, Robert Caplan’s analysis of The American Society of Anesthesiologist (ASA) Closed Claims Projects revealed that of the 80 medication-error claims studied, 44% were the result of anesthesia administered at the wrong dose. Furthermore, a study published by the Canadian Journal of Anesthesia also found that anesthetists experienced more than one drug error in their practice with syringe swap being the most prevalent category.

The standard and goals for reducing medication errors set by regulatory agencies like the Institute for Healthcare Improvement, Centers for Medicaid and Medicare Services, Institute for Safe Medication Practices (ISMP) and Joint Commission should form the basis of the process all anesthetists follow. Any deviation could increase your liability giving rise to serious malpractice issues.

We welcome your ideas on processes that improve anesthesia services. Leave a comment on our blog below.