Chapter 11 - Enhancing medication safety during the perioperative period

Abstract

The perioperative environment is complex and marked by high degree of safety hazards. Patients continue to suffer from medication harm despite 40 years of research; anesthesia providers have been slow to recognize the implications and acknowledge the extent of the problem. A medication error is any mistake in the intended use of a medication (eg, wrong medication, wrong dose, or infusion of the wrong medication into the wrong place). The perioperative period is a high-risk setting for such errors. This chapter focuses on prevention of medication errors in the perioperative setting. We review what medication adverse events are, and how often and where these errors occur, as well as exploring human cognitive psychology and explaining why things can go wrong at any time in a complex system. The goal is to aid surgical team members to better appreciate the complexity and human factors risks of the medication use process. Despite advances in safety practices, the perioperative medication administration remains one of the most vulnerable for unsafe patient outcomes due to several reasons. For example, the intraoperative medication process—managed primarily by anesthesia providers—lacks key safety guardrails enjoyed by practitioners in other areas of the hospital. Medications are primarily ordered, dispensed, prepared, administered, and monitored by the same anesthesia provider, removing the potential for valuable safety checks by other clinicians such as pharmacists and nurses. Additional factors also contribute to this safety vulnerability including, but not limited to, poorly designed technology and user interfaces, uncertainty of patient information, cognitively demanding tasks and a lack of appropriate support, poor teamwork, ambiguous communication, inadequate work coordination, and a poor unit culture. Utmost attention should be paid to the context and culture of the perioperative care environment. Not taking this into consideration will likely undermine medication safety technology implementation including the willingness to report on near misses and harmful events. Continuous participation of clinicians is essential during all steps of technology design to ensure meaningful appreciation of the complex challenges and risk trade-offs, in implementing new technology. Increasing interprofessional collaboration will also be key to enhance medication safety in the perioperative setting. Often, clinicians from diverse backgrounds such as pharmacists, nurses and physicians, will have different goals and expectations with respect to achieving safety and the means to achieve these goals. This is partly attributed to the differences in socialization and disciplinary culture, norms, and how clinicians are trained within their respective fields of study. The Covid-19 pandemic has challenged patient safety and introduced communication and process breakdowns. The fact that the pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure.