Avoiding Medication Errors

Humans are fallible and unfortunately medication errors can occur easily. On my hospital’s wards, and indeed on most hospital wards, when medications are drawn up, the nurse must check the medications, dosage and labeling with another nurse before administering the medication. In fact, in my hospital the pharmacist also checks all of the orders to make sure allergies and other drug conflicts have not been overlooked. This is a wonderful safety feature, but it’s time consuming and labor intensive.

In the OR, during anesthesia, things are happening quickly – too quickly to have a second person constantly checking each medication draw. The anesthesia provider is drawing and administering the medications solo. That added responsibility means we have to be extra vigilant. There are many things that can predispose to medication error

A Mistake From My Own Past

Picture of multiple syringes and vials on a work station

It’s easy to grab the wrong syringe if your work station is not organized.

It can happen to anyone, even me. About twenty five years ago I was giving a routine “local with sedation” anesthetic in a healthy patient. One of the CRNAs came in to see if I needed anything. As I was talking to my colleague, my patient said he was still nervous. I told the patient, who had already received some valium, that I would give him a “little more medicine that would help him relax“. At that point I accidentally picked up the 5 ml anectine syringe rather than the 5 ml valium syringe.

As the CRNA watched me, I injected 1 ml of anectine. It had the effect that you might imagine. The patient fasciculated and got short of breath. I immediately gave a little pentothal to put the patient to sleep for the few minutes it would take for the small dose of anectine to wear off and supported his breathing. Fortunately the patient did very well and didn’t remember a thing.

While I was treating the aftermath of my mistake the CRNA, looking very uncomfortable, tentatively said “I never would of thought about using anectine to help a patient relax.” After a pause, I told him that hopefully he would never see that technique used again.

Several things happened here:

  • I was lulled into a false sense of security because the case was easy.
  • I was distracted by a conversation.
  • I picked up the wrong syringe based on syringe size and did not read the label before injecting it
  • My CRNA colleague saw me about to make a mistake but did not feel empowered to point it out before I pushed the plunger. It turned out he had been publically berated by another one of the anesthesiologists about “questioning the plan” and decided it was safer for him to say nothing.

This last is a human tendency. Airplanes have crashed because a copilot didn’t feel he or she could safely point out to the pilot that the plane was almost out of gas or that the wings were icing up. It shows just how conflict avoidant humans can be if a copilot is willing to risk personal death rather than be potentially yelled at. Humans are conflict avoidant to a fault, and we are far from perfect — a very dangerous combination.

Causes of Medication Errors

Picture showing typical drug drawer with multiple drugs and look alike vials and syringes.

Multiple drugs come in vials that look alike, making mistakes easier to make.

  • Large variety of drugs on the cart or in the cabinet
  • Disorganized drug storage: too easy to grab the wrong vial
  • Using acronyms for names
  • Similar names
  • Distractions and multitasking
  • Fatigue
  • Math errors calculating the dose
  • Misreading the decimal point
  • Inadequate training
  • Lack of pharmacological knowledge
  • Illegible prescription/writing
  • Incomplete labeling, abbreviations
  • Failure to follow safety protocols

Let me repeat, humans are fallible. There are plenty of distractions when working long hours, when working in a darkened room wearing tinted laser goggles to allow the ophthalmologists to work, or when working during an emergency where time is of the essence. It is easy to think you see what you want to see in those circumstances. Medication errors are easy to make if we aren’t careful.

Safety Steps When giving Medications

However, this incident taught me a valuable lesson. From that point on I tried to mistake proof myself when giving medications. Every time I give a medication I perform the following steps. And I teach my students to follow these same steps.

Read The Label On The Vial

Look alike syringes labeled to alert provider.

Look alike syringes increase risk. Our pharmacy puts alerts on these to increase our awareness.

As I am picking up the vial, I force myself to slow down and read the label. Vials come color coded these day. When we’re in a hurry, the best of us can get lazy and settle for pattern recognition. Why is this dangerous? Some drugs come in look-alike vials. Pharmacies may change suppliers: look/color of the vial can change without warning. The staff restocking carts sometimes put the wrong vial in the wrong bin. Suppliers change drug concentrations.

You can never be sure that the vial you’re picking up isn’t a surprise unless you read the label.

Read The Vial Label Again

Picture of vial and labeled syringe

Always reread your vial and the syringe multiple times to check correctness.

After I finish drawing up the medication, I reread the label on the vial again. Trust me, sometimes we initially see what we want to see, especially if we are in a rush.

Immediately Label the Syringe

I label that syringe unless I am injecting it immediately. If you are going to put that syringe down — even for a minute— label it first. And each syringe should be labeled with drug name, dose, and concentration. I carry a sharpie pen in my pocket so I can label the syringe directly if I don’t have a stick-on label.

And don’t draw up a bunch of syringes of different medications and then label them as a group. They will all look alike filled with clear solutions. Don’t depend on the size of the syringe to tell you which drug is which. Always label them one at a time.

Label the syringe clearly

Label syringes clearly- don’t use abbreviations. One of the residents once injected 5 ml of neosinephrine (500 mcg) rather than 5 ml of neostigmine (5 mg) during reversal of muscle relaxation because the neosinephrine syringe on the cart had been labeled simply “neo”. The result was much more exciting than it needed to be.

Using Zeroes Safely

Picture of labeled syringe with drug name, concentration and date.

Always label your syringes completely with drug name, concentration and date. Note “leading” zero before the decimal point. Always use leading zeroes. Never use following zeroes.

When labeling, and when writing orders, always use leading zeroes before the decimal point. An example of a leading zero is: 0.5 mg/ml. A leading zero alerts the reader that we are dealing with a very low dose and concentration.

Never use following zeroes. An example of a following zero is: 10.0 mg. It is too easy to misread this as 100 mg, which is 10X the dose.

Read the Syringe Label Before Attaching It to The Injection Port

When I am getting ready to inject an IV medication, I read the label when I pick the syringe up, and then I always reread the label  before I attach it to the injection port.

Reread The Label Before Pushing The Plunger

After I insert the syringe tip into the inject port, I stop and reread the label one more time before I push the plunger. All of this rereading just takes a second or two. This is your last chance to catch a mistake. Don’t miss it.

Don’t Be Afraid To Have Someone Check the Dose

If you are giving a medication that you rarely administer, especially one where dosing is critical and you have to calculate the dose, ask someone to check your math. I have nothing against calculators, but I am sadly finding that some of my students in this newest professional generation are dependent on calculators to calculate dosages and seriously weak on being able to do the math on their own. The problem with this is twofold:

  • you may not have a calculator
  • if you hit the wrong button on the calculator, especially the decimal point, you can get a very wrong dose. Mental math at least tells you the ball park figure to expect

Never be afraid to ask for someone to check the dose. Remember, nursing staff have to do that on the wards routinely. It doesn’t hurt us to do it for critical medications.

know the drug

I almost didn’t include this one because it should go without saying that we should know the dosage, side effects, and major interactions of the drugs we’re using. But today there are so many new medications that occasionally the first time I will see a drug is when the surgeon hands it to me in the OR for a particular surgery. Don’t be afraid to stop and read the package insert, look in the PDR, “google” it, or even call pharmacy.

You don’t want to be the provider who causes the cardiac arrest by pushing the 2 gm of Mg in less than 5 minutes (instead of slow infusion over 60 minutes) on labor and delivery while treating preeclampsia.

Empower Your Helpers To Yell Stop!

Make sure your helpers know that they should question you if they have a concern about anything that you are about to do. This is especially true if you know you are compromised. We all have days when we have been distracted by a death or serious illness in the family, or when our teenager has wrecked the car, or when we simply have not had enough sleep the night before. Your team can watch your (and your patient’s) back on those hopefully rare occasions.

And when your team gives you feedback or questions you, accept their comments gracefully. If there is no problem thank them for verifying and explain why you are doing what you’re doing. Trust me.  Someday your team member will point out something to you that you really do want to know and it will help prevent potential disaster.

Check the Infusion Pump Twice

Before we leave the topic of safe injection of medications, let me remind everyone that even with some of the  sophisticated safety features that some of our infusion pumps have, it is sometimes very easy to mis-program them. Moving a decimal point, for instance, can have catastrophic consequences. Check the programming before you hit start. This is especially true if you are programming multiple pumps quickly in a critical situation.

This almost happened to me the other day. I had a seriously ill patient who had 4 vasoactive drugs running in an emergency procedure. Bumping the pump caused it to lose it’s programming, requiring reprogramming all 4 channels at a critical moment in the case. One pump almost got reprogrammed at a rate 100 times the original dose because I misplaced the decimal point on the concentration. However, following my check and check again strategy I thankfully caught it before I pressed the start button.

If you follow these steps, not only can you prevent medication errors — but someday you will catch yourself about to make an error before it happens. That’s what you want to do: catch those mistakes before they happen. And while you’re at it, don’t forget to teach your students to follow these safety steps.

Right drug, right dose, right time should be our motto.

May The Force Be With You

Christine Whitten MD


To cite this post: Whitten, C.E. (2015, September 25) Avoiding Medication Errors [Web log post], Retrieved from http://airwayjedi.com/2015/09/25/avoiding-medication-errors

7 thoughts on “Avoiding Medication Errors”

  1. Another great post Dr Whitton, i go to lectures where they bandy the word airway guru about like lolliwater and what i mostly see is celebrity drs pushing hugely expensive and sometimes illogical or untested methods and they have have far less experience than you, whereas you have literally written the book, -Anyone can intubate, a book i haven’t book quite yet, not fiscally rich but out of respect for your teaching donated about same amount to operation smile instead,
    I did a cric study ages ago and would like to do a follow up one for dr Melker, made an airway model for $200-300 instead of the ludicrous $20-63 000,fees i see now
    simulation to a degree has become it’s own business
    Thanks for the teaching hope to relay your info to juniours if given the chance
    to me your teachings are a lession in the skills of logic meticulousness expertise
    o and i forgot, during an anaesthetic term, one young anaesthetist who wasn’t keen on me and often showed off, did give the sux before the thiopentone and scrambled to regain composure
    to me ego can get in the way of patient care as well
    treating the ego often can lead to mistakes, like causing the hesitancy in your assistant due to prior experience with another anaesthetist

    i like to limit as many unnecessary factors as possible, and know the stuff i use intimately
    simple, succint, effective
    cheers have a nice day 🙂

    1. Thank you so much for the compliment, and for the donation to Operation Smile. That was very thoughtful of you. I too have had residents who felt that they should demonstrate their superior “knowledge. I distinctly remember one animated discussion I had with a resident who wanted to prove to me that nasal intubation with the stylet in place would be ever so much easier since the tube would already be shaped to turn the corner. Needless to say I did not allow him to try that technique that day, or any other day. Finding the fine line between building a trainee’s confidence and independence, allowing him or her to try different things, yet keep patients safe in the process, can be challenging at the best of times.

      I am trying to provide practical information with this website but am not sure about who is reading. Let me know your backgrounds and interests. I am very much open to suggestions on what you and my other readers would like me to write about. Everyone should feel free to send me suggestions on you want to read about.

      Those who do not feel comfortable sending comments to me on this public forum can also reach me at anyonecanintubate@yahoo.com.
      May the force be with you
      Chris Whitten

      1. thank you Dr Whitten, your the best,-fine line between building a trainee’s confidence and independence,

        the old empower and mentor, balancing act 🙂

      2. sorry forgot,
        Dr Whitton your resident in nasal intubation, wanted to turn the corner with a stylet, which corner the nasal passage is straight, get through that first

        i love stylets,
        they can flex but they are also hard
        recently tried intubation after years, on model airway,

        used bougie which i never really use, out of interest tried it, failed ETT intubation on model,got stuck railroading,

        that has only happened to me once or twice ever,,that i can recall, this time and maybe my first look down were had no idea what was looking at, with superviser next to me, and never had failed intubation/failed ventilation scenario, so far.. <- this prevents complacency

        but trusty stylet specifically in this situation, bang bang bang, 3 attempst 3 passes,100% that's what i want for, that's what i aim for, like riding a bike, after years

        cheers thanks

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