How can administrators ensure medication safety?

To ensure medication safety in your program, perform regular safety rounds in perioperative areas to observe labeling procedures, promote consistency, and inquire about barriers to implementing this safety practice, advises the Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, PA.

Administrators should not neglect back rooms such as pain management and endoscopy, advises Betsy Hugenberg, BSN, MSA, RN, CIC, senior health care consultant with AIG Consultants, Healthcare Management Division, in Atlanta. "Make sure what you think is going on, is," she stresses.

Insurers have indicated to Hugenberg that sometimes there are nonlabeled medications in the pain management areas. Programs often have prepackaged trays that have wells to be filled with fluids for injections. Managers should ensure medications are monitored and when they’re drawn up, they’re labeled and not left unattended, Hugenberg says. She knows of two instances in which radiographic contrast was confused with other solutions (a skin prep solution and an injectable anesthetic). In one of those instances, the incorrect medication was injected under the patient’s skin, she says.

Tell memorable stories to perioperative staff about tragic mix-ups that have occurred in other facilities when medications and solutions were unlabeled on the sterile field to help motivate practice changes, ISMP advises. A multidisciplinary perioperative safety team that includes nurses, technicians, pharmacists, and physicians also might help to improve consistent labeling, the institute says.

Janice Izlar, certified registered nurse anesthetist at Georgia Institute for Plastic Surgery in Savannah, says, "As a patient advocate, I have posted every article I have read about this potential danger in our facility, and it has been discussed during inservice meetings to heighten awareness of the dangers."