Despite the fact that the perioperative setting, including the preoperative area, operating room, and post anesthesia care unit, is one of the most medication-intensive areas in a hospital, with a greater percentage of high-alert medications used compared to regular units, the medication-use process generally lacks the standard checks and balances performed on traditional inpatient units, and, frequently, there is little involvement by pharmacy. Often, medication doses and concentrations are not standardized, and in many cases, there is a lack of protocols or, if present, they routinely are not followed. Medication labeling in this setting is often less than optimal and there is a greater potential for look-alike/sound-alike medications to pose problems based on medication storage practices. Finally, reporting of medication errors in this setting is, at times, less than optimal. With this in mind, it is vital that pharmacy take a critical look at the medication-use processes in place in the perioperative setting and work toward implementing technology and practices to support medication safety efforts. There are many risk reduction strategies that can be employed to help institutions improve safety in this setting.

Pharmacist Presence
Pharmacy presence can significantly impact medication safety efforts in the perioperative setting. When physically present, pharmacy staff can more easily integrate into the medication-use process, from reviewing medication orders to overseeing medication preparation and dispensing, and it is easier to perform activities such as staff education and quality improvement projects. One of the greatest advantages of having a pharmacist in this setting is improved communication. Issues and concerns can be shared in real time as opposed to perioperative staff having to remember to call pharmacy when time permits. Ideally, pharmacy services would be provided out of an operating room pharmacy, allowing a pharmacy technician to be part of the staffing complement as well. Given the uniqueness of this environment, pharmacy staff in the perioperative area needs to receive appropriate training. Keep in mind, pharmacy can still impact medication safety even if a physical presence is not possible. For example, critical care infusions and specialty solutions can be prepared in the pharmacy’s cleanroom and then transported to the operating room—eliminating the need for anesthesia providers and nurses to prepare them. Likewise, pharmacists can still assume a major role in medication-related quality improvement initiatives (eg, anti-infective prophylaxis) even if not based in the perioperative setting by sitting on the OR’s quality improvement committee.

Ready-to-use Medications
The Joint Commission (TJC) standard MM.05.01.07 states that sterile preparations are to be prepared by pharmacy except in emergent situations, and while many institutions are doing a good job meeting this standard in their inpatient units, it remains a challenge in the perioperative setting. Providing medications in ready-to-use (RTU) form can help with compliance, so it is important for pharmacy to work with anesthesia and other providers to identify the ideal preparation method for each medication used in the operating room. Depending on the medication and the preferences of the institution, pharmacy may opt to compound the product in-house, use an outsourcing company, or purchase a commercially prepared or point-of-care activated product. Recently, attention has been given to outsourced anesthesia syringes (see “Outsourced Pre-filled Syringe Conversion in the Operating Room” in this month’s Cleanrooms & Compounding supplement). Given their focus, labeling and beyond-use dating is often better with these syringes than what most institutions can provide with in-house preparations.

Standardization
One risk reduction strategy that can have a significant impact on patient safety is increased standardization. Some standardization measures to consider include:

• Medications and concentrations: Look at standardizing critical care infusions, anesthesia syringes, epidurals, irrigations, and antibiotics.
• Protocols and order sets: Standardize the medication component of protocols and develop order sets based on these protocols. Make sure the order set is updated as changes are made to the protocol.
• Anesthesia tray or cart contents: Do not provide excessive quantities of medications, especially rarely used ones, in the anesthesia tray or cart. Arrange medications in the tray or cart to avoid confusion (eg, physically segregate look-alike/sound-alike medications). Furthermore, avoid storing concentrated medications in the tray or cart. In our institution for example, insulin vials are not allowed in the anesthesia tray. Set up and label the anesthesia tray or cart in a uniform manner; this prevents confusion if the anesthesia provider is required to move to a different OR suite.
• Case kits: Standardize medication case kits by surgical procedure, not by surgeon (see Table 1). Making kits surgeon specific results in numerous variation, and can lead to errors.
• Medication storage areas: Do not maintain excessive quantities of medications in storage areas. Medications should be arranged in a consistent, organized manner. For example, store medications for external use, for irrigation, for respiratory use, and for parenteral use separately. Clearly and accurately label all storage bins, using generic drug names when possible. In addition, use tall-man lettering when appropriate.
• Automated dispensing cabinets: Automated dispensing cabinets in the perioperative area can bolster inventory control efforts and provide useful reports. Access can be limited to only those individuals responsible for medication gathering and preparation. Keep in mind, automated dispensing cabinets are not fail safe and medication errors can still occur with their use.

Medication Labeling
TJC’s NPSG.03.04.01 requires that all medications, medication containers, and other solutions on and off the sterile field be labeled in the perioperative and other procedural settings. Incidentally, this was the medication-related NPSG scored non-compliant with the highest frequency (27%) in 2009. To help ensure appropriate labeling in the perioperative setting, make preprinted labels available and include the concentration whenever possible (this is only feasible if a single concentration is used). It is important to keep an adequate stock of labels in each OR suite so they can be used when needed. Consider using the American Society for Testing and Materials’ (ASTM) color-coding standards for user-applied anesthesia syringe labels. Instruction on the appropriate labeling of medications needs to occur on a routine basis to underscore the importance of this requirement. In addition, perform periodic audits to assess labeling compliance.

Automation and Technology
As in any other area of the hospital, the goal of incorporating automation and technology into the perioperative medication-use process is to improve the efficiency and safety of medication use. Some examples of technology that can help with this include smart IV pumps, bar code medication administration software, automated dispensing cabinets, anesthesia information management systems (AIMS), and automated anesthesia carts. Currently under development is a drug-syringe label printer that will produce TJC-compliant labels in the OR suite for use by anesthesia providers.

Automated anesthesia carts are designed to complement the anesthesia provider’s workflow, and these specialized carts have the capacity to store securely the required medications, controlled substances, and supplies while granting easy access to medications during surgery. In addition, they can accurately track medication usage and waste, as well as facilitate accurate charge capture. At least one of the commercially available automated anesthesia carts now has the capability to print syringe labels.

Perioperative Medication Safety Officer
Most institutions have a medication safety officer, and often this designated staff member is a pharmacist. If the hospital has an OR pharmacist, this person can informally serve as the perioperative medication safety officer and work in conjunction with the institution’s official medication safety officer. The perioperative medication safety officer can manage medication safety-related issues in the OR, such as the use of high-risk medications, and perform failure modes and effects analyses when appropriate. This person also can coordinate programs to improve the reporting of medication errors and chair the multidisciplinary OR safety committee, which is responsible for reviewing errors and developing and implementing the necessary procedures for error prevention. In addition, the perioperative medication safety officer can ensure that various medication-related audits are performed and identify corrective action if necessary.

Quality Improvement Initiatives
Given the medication-intensive nature of the perioperative setting, it is important for a formalized quality improvement process to be in place. Many institutions have an OR multidisciplinary quality improvement committee consisting of surgeons, anesthesia providers, nurses, and pharmacists. This committee can address issues such as compliance with the Centers for Medicare and Medicaid Services core measures, use of alternative medications before surgery, medications to discontinue prior to surgery, and insulin use in the perioperative setting.

Drug Information
Often, medication errors occur due to a lack of thorough and up-to-date drug information. As such, drug information resources in the perioperative setting need to be current, easily accessible, and available in a variety of formats, such as books, PDA-based applications, and the hospital intranet. Having a pharmacist in the perioperative setting provides an invaluable source of drug information for the other health care providers there.

Formulary Management
Periodically assess medications used in the perioperative setting and remove redundant or low-use items from the formulary. Not having these medications physically present eliminates the chance they will be used in error. It also is beneficial to have a surgeon or anesthesiologist serving on the pharmacy and therapeutics committee as this will provide a valuable perspective on medications used in this setting.

Medication Purchasing
There are several purchasing strategies that pharmacy can employ to help reduce the risk of medication errors occurring in the OR. Whenever possible, purchase medications in unit-of-use form to help decrease the chance of dosing errors from a misread vial or ampoule. Also, try to purchase as many pre-made medications as possible including critical care infusions, anti-infectives, and epidurals; this will eliminate errors that might occur during the preparation process. Make sure to limit sizes and formulations of medications to those truly needed. Finally, perform an ongoing assessment for look-alike/sound-alike products; if any are identified, consider purchasing product from a different manufacturer or, if this is not possible, try to procure the product in a different-sized container. Remember to inform perioperative staff when changing manufacturers or when a current product has new labeling.

Education
It is important that all health care providers involved with medication preparation and/or administration in the perioperative setting receive appropriate education on the medications they will be handling. For new hires, this education can be integrated into the training process. For current employees, medication and medication-related information (eg, policies and procedures, protocols, new formulary medications) can be communicated through a variety of methods including inservices, memos, e-mails, newsletters, and one-to-one discussions; the appropriate method depends on the type of information that needs to be communicated. In addition, develop competencies for medication-related activities to ensure that staff maintains proficiency in these activities. A pharmacist practicing in the perioperative setting can take a leadership role in providing much of this education.

Conclusion
As the medication experts, it is critical that pharmacy spearhead medication safety efforts in all areas of the hospital—especially the medication-intensive perioperative setting. By implementing risk reduction strategies, institutions can help bolster patient safety in this area of the hospital. While having a pharmacist located in the perioperative area certainly makes it easier for pharmacy to take a leadership role there, medication safety efforts in the perioperative setting can still be managed by pharmacy without this localized support.

References:

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Andrew J. Donnelly, PharmD, MBA, FASHP, is the director of pharmacy services at the University of Illinois Medical Center at Chicago and clinical professor in the Department of Pharmacy Practice at the University of Illinois at Chicago College of Pharmacy.