Syringe size and medication errors

Abstract

Editor, Medication errors continue to be an issue in contemporary anesthesia practice. A recent study and an accompanying editorial about medication errors made by anaesthesia providers(1Nanji KC Patel A Shaikh S Seger DL Bates DW Evaluation of Perioperative Medication Errors and Adverse Drug Events.Anesthesiology. 2016; 124: 25-34Crossref PubMed Scopus (157) Google Scholar, 2Orser BA Cohen DU MR Perioperative Medication Errors: BuildingSafer Systems.Anesthesiology. 2016; 124: 1-3Crossref PubMed Scopus (9) Google Scholar), although published elsewhere, should be of interest to all perioperative physicians. A “syringe swap” involving a muscle relaxant has previously been identified as the most common drug error reported by Canadian anesthesiologists.(2Orser BA Cohen DU MR Perioperative Medication Errors: BuildingSafer Systems.Anesthesiology. 2016; 124: 1-3Crossref PubMed Scopus (9) Google Scholar) Using information from an anaesthesia incident reporting system employed at large Norwegian teaching centre, muscle relaxants were the most frequent medication class involved in a drug error.(3Orser BA Chen RJ Yee DA Medication errors in anesthetic practice: a survey of 687 practitioners.Canadian Journal of Anesthesia. 2001; 48: 139-146Crossref PubMed Scopus (138) Google Scholar) Interestingly, Fasting and Gisvold also found that the overwhelming majority (27 out of 28 errors noted) of syringe swap medication errors in perioperative care involved syringes of equal size.(4Fasting S Gisvold SE Adverse drug errors in anesthesia, and the impact of coloured syringe labels.Canadian Journal of Anaesthesia. 2000; 47: 1060-1067Crossref PubMed Scopus (133) Google Scholar) To reduce such errors, Jensen et al. identified avoidance of similar packaging and presentation of drugs as important strategies to enhance safety surrounding medication administration.(5Jensen LS Merry AF Webster CS Weller J Larsson L Evidence-based strategies for preventing drug administration errors during anaesthesia.Anaesthesia. 2004; 59: 493-504Crossref PubMed Scopus (177) Google Scholar) Anaesthesiologists have been encouraged to adopt evidence-based strategies, such as formally organizing drug drawers and workspaces, in addition to labeling syringes.(5Jensen LS Merry AF Webster CS Weller J Larsson L Evidence-based strategies for preventing drug administration errors during anaesthesia.Anaesthesia. 2004; 59: 493-504Crossref PubMed Scopus (177) Google Scholar, 6Shultz J Davies JM Caird J Chisholm S Ruggles K Puls R Standardizing anesthesia medication drawers using human factors and quality assurance methods.Canadian Journal of Anesthesia. 2010; 57: 490-499Crossref PubMed Scopus (18) Google Scholar) Recently, the Institute for Safe Medication Practices (ISMP) added to their list of Best Practices the concept of differentiating all neuromuscular blocking agents from other medications.(7Institute for Safe Medication Practices (ISMP) 2016-2017 Targeted Medication Safety Best Practices for Hospitals.Available from URL: http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdfGoogle Scholar) Building upon these practices, I wish to bring to readers' consideration use of a 10-mL syringe when preparing muscle relaxants to potentially help reduce the likelihood of administering a neuromuscular blocking agent out of the intended sequence. Having personally used this technique for several hundred patients inan adult, non-cardiac, academic health centre, I find that the commonly used co-induction medications can be easily divided into muscle relaxants and non-muscle relaxants. In addition to the visual input from a drug label, the size of the 10-mL syringe provides another sensory modality –––tactile feedback––– to discriminate one medication group (in this case the muscle relaxant in a 10-mL syringe) to be administered from another (non-muscle relaxant). Moreover, preparation of neuromuscular blocking agents in 10-mL syringes fits well with medication volumes and concentrations currently available for clinical use. For the vast majority of adult patients, 3-mLor 5-mL syringes contain dose-appropriate volumes of midazolam, lignocaine, fentanyl, and ketamine for induction of anesthesia. In contrast, succinylcholine (20 mg/mL) and cisatracurium (2 mg/mL) frequently require greater than 5 mL volumes for adult patients. Of course, one must be mindful of the presence of other commonly usedperioperative medications, e.g., antibiotics, tranexamic acid, opioids, vasopressors, et cetera, that could be contained in a 10-mL syringe. Applicability of this practice to other domains, such as cardiac or pediatric anesthesia, warrants careful evaluation. The evidence-based recommendations aimed at enhancing the safety of intravenous medication administration(5Jensen LS Merry AF Webster CS Weller J Larsson L Evidence-based strategies for preventing drug administration errors during anaesthesia.Anaesthesia. 2004; 59: 493-504Crossref PubMed Scopus (177) Google Scholar, 6Shultz J Davies JM Caird J Chisholm S Ruggles K Puls R Standardizing anesthesia medication drawers using human factors and quality assurance methods.Canadian Journal of Anesthesia. 2010; 57: 490-499Crossref PubMed Scopus (18) Google Scholar) are not intended to be applied in isolation. More work remains to be done regarding the role different sized syringes could have on syringe swap error involving muscle relaxants, especially in clinics and hospitals where point-of-care, bar-code identification of medications remains untenable. Indeed, one size does not fit all when it comes to reducing medication errors. Conflict of Interest: