Key result
Standardization of 36 anesthesia medication trays resulted in 83 total changes, including 60 medication removals and the replacement of high-risk medications with ready-to-use syringes, to decrease the opportunity for human error.
An interdisciplinary project successfully standardized anesthesia medication trays, implementing 83 changes to reduce the opportunity for human error in the operating suite.
May support anesthesia tray standardization to reduce error risk; hypothesis-generating and requires outcome validation before practice change.
Background: Medication errors cause an estimated 100,000 to 400,000 patient deaths in the United States annually (IOM). Previous reviews on this alarming statistic consistently identify human error as the most common etiology. The potential for medication errors is especially high risk in the operating suite, where the provider simultaneously selects, doses and verifies medications to be administered to patients. Additionally, a lack of standardization and error reduction strategies in this setting creates the environment for medication administration errors, prompting multiple recommendations for interventions to minimize human error.
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Smith et al. (2018) studied Anesthesia medication safety. Standardization and reconfiguration of anesthesia medication trays vs. Pre-intervention tray configuration was evaluated on Number of changes made to anesthesia medication trays. Standardization of 36 anesthesia medication trays resulted in 83 total changes, including 60 medication removals and the replacement of high-risk medications with ready-to-use syringes, to decrease the opportunity for human error.
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