A patient was under the care of a resident and an attending anesthesiologist. The resident intended to draw up 0.2mL of 1mg/mL morphine from the Pyxis, but inadvertently removed a 10mg/mL morphine vial instead. The resident verbally confirmed “0.2 of morphine and 15 of fentanyl” to the anesthesiologist as the anesthesiologist administered the medication spinally. When the anesthesiologist subsequently wasted the residual narcotic, she noticed that the vial was 10 mg/mL instead of 1 mg/mL. The pharmacy was contacted and the patient was started on a naloxone drip with symptoms of sleepiness, nausea, and itching. The patient remained in postop to be closely monitored until symptoms resolved and naloxone was weaned off.

“Hospital and department leadership can foster a strong culture of safety by setting expectations that prioritize safety, establishing safety protocols, strengthening teamwork through training, and leading by example.”

Medication errors in the OR are common and have considerable potential for harm. In fact, due to the fast-paced clinical environment, high acuity, and rapidly changing patient condition, medications are typically administered without prospective medication orders, double-checks by second providers, or electronic checks to warn of medication errors. As a result, medication errors are the most frequently cited error type in anesthesia. A medication error is defined as a failure to complete a required action in the medication use process, or the use of an incorrect plan or action to achieve a medication-related patient care aim (Crit Care Med 2005;33:1694-700; Anesthesiology 2016;124:25-34). Medication errors can occur anywhere along the medication use process and include errors of commission (e.g., wrong dose, wrong route) or errors of omission (e.g., missed antibiotic) (Anesthesiology 2016;124:25-34). Medication errors can lead to adverse medication events (AMEs), which are instances of patient harm or injury due to medication use, regardless of whether an error in the medication use process occurred (Anesthesiology 2016;124:25-34). Observational studies have shown that 4%-10% of perioperative medication administrations, or every second operation, involve a medication error (Anesthesiology 2016;124:25-34; BMJ 2011;343:d5543). About half of these lead to observed patient harm and the remainder have the potential for patient harm, with more than two-thirds of the harm classified as serious or life-threatening (Anesthesiology 2016;124:25-34). The cost of harm due to perioperative medication errors is $5.3 billion annually in the United States, and 95% of the errors are preventable (Anesthesiology 2016;124:25-34; J Patient Saf 2021;17:e758-e64; Anesth Analg June 2024).

Strategies to prevent medication errors typically fall into the following categories: standardization, pharmacy, institutional, and technology strategies. We will review some of these strategies, with a focus on those that could have prevented the error described in this case. Standardizing concentrations of medications, especially high-alert medications, within an institution or within a clinical care area (e.g., cardiac, pediatrics) is an effective medication error prevention strategy. Fewer concentration options can decrease provider uncertainty, reduce operational variations, and improve consistency, especially during transitions of care or situations involving multiple clinicians (asamonitor.pub/4cQrTTZ). In this case, one standard concentration of morphine may have eliminated the reported error altogether. The pharmacy can also implement strategies to prevent medication errors. For instance, storing regional anesthesia medications separately from standard medications that may contain preservatives serves to prevent inadvertent administration of a nonpreservative-free medication intrathecally, as may have occurred in this case. Additionally, providing prefilled syringes reduces the incidence of vial selection errors (Ann Emerg Med 2015;66:97-106). While prefilled syringes may have higher unit costs than vials, they reduce errors and waste while improving efficiency, aseptic conditions, and safety (Anesthesiology 2016;124:795-803; J Infus Nurs 2022;45:27-36).

Institutional culture and processes play important roles in preventing (or, conversely, facilitating) errors. For example, strong and effective communication within the anesthesia care team is essential for preventing medication errors. This is especially important when the clinician drawing up/preparing medications is not the same clinician administering the medications. Several lapses in communication occurred in this case. First, the resident did not include all relevant information when confirming the medication and dose with the anesthesiologist; verbal confirmation should include med name, dose, and concentration, with all applicable units. Second, the attending anesthesiologist did not use closed-loop communication. In closed-loop communication, the receiver paraphrases/repeats the message back to the transmitter, followed by confirmation or correction of the message by the transmitter (J Patient Saf 2023;19:93-8). If closed-loop communication of the required information was used in this case, the clinicians may have noticed that the concentration was incorrect. Effective communication can be facilitated by a robust culture of safety. In fact, several studies have shown strong links between a positive safety culture and positive perioperative outcomes (J Am Coll Surg 2019;229:175-83). Hospital and department leadership can foster a strong culture of safety by setting expectations that prioritize safety, establishing safety protocols, strengthening teamwork through training, and leading by example (asamonitor.pub/3xLzBju; Br J Anaesth 2017;118:32-43).

There are also technological innovations that can prevent medication errors such as the one described in this case. Specifically, clinical decision support tools that provide medication checks prior to medication administration have the potential to prevent 95% of intraoperative medication errors (Anesthesiology 2016;124:25-34; Anesth Analg June 2024). These tools provide auditory and visual feedback as well as algorithms that display alerts and other critical information (BMJ 2011;343:d5543; J Am Med Inform Assoc 2022;29:1416-24). In fact, professional organizations such as the Institute for Safe Medication Practice and the Anesthesia Patient Safety Foundation have recently released recommendations for the use of electronic point-of-care medication checks with clinical decision support in the OR (asamonitor.pub/4eLraVU; asamonitor.pub/3y7gGuD). While not yet widely adopted, there is evidence to support the efficacy of these tools in preventing medication errors and improving anesthesia workflows (BMJ 2011;343:d5543; J Am Med Inform Assoc 2022;29:1416-24).

In summary, important strategies to prevent medication errors include standardization, pharmacy, and institutional and technology tools. We have focused on the strategies that are most relevant to this case to provide examples of how they work to prevent medication errors in practice.