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Medical errors are estimated to be the third leading cause of death in the United States1 and pose a large financial burden to the healthcare system.2 Medical errors in anesthesiology are common, reported to be as high as 1.12% during general anesthesia.3 Further, one study found that one in twenty perioperative medication administrations included a medication error or adverse drug event.4 There are also strict regulations for the preparation, security, and use of medications for public health and safety reasons. These two areas motivate the application of best practices for drug preparation and dilution in anesthesia.
A dual-center study involving 7794 anesthesiologists uncovered that 20% of drug administration errors were due to incorrect dosing, with drug substitutions comprising an additional 20%,5 making drug preparation and dilution significant routes for the introduction of anesthesia errors leading to the increased risk of morbidity and mortality.
To mitigate the likelihood of medication error or adverse drug event related to drug preparation, best practice frameworks have been proposed. Mackay, Jennings, and Webber’s6 best practices can be divided into three categories: strategies to attenuate the risk of infection associated with drug preparation, strategies to optimize the environment in which the drug is prepared, and other best practices.
Strategies to minimize the risk of infection during drug preparation for anesthesia include performing effective hand hygiene and using 70% alcohol wipes to swab vial tops and injection ports prior to injection. Further, ampoules and vials should not be recycled; instead, they should be used only once, and materials should be stored in clean spaces.6
Optimizing the environment in which drug preparation takes place also minimizes the introduction of errors. Some strategies include ensuring adequate lighting for clear visualization and confirmation of materials and medications, minimizing clutter to facilitate easy identification and immediate access to materials, and minimizing distractions which introduce errors during preparation.6
Additional strategies include preparing one medication at a time rather than multiple, simultaneously, to mitigate the likelihood of conflating medications. Following each use, syringes should be discarded; this is particularly salient for non-compatible medications.6
Best practices for dilution in anesthesia are similar to those for drug preparation, as preparation often encompasses dilution. More system-level best practices are discussed in the American Society of Anesthesiologists’ “Statement on Drug Concentration Standardization.”7 One of these recommendations was encouraging drug manufacturers to produce set dosages which can be readily diluted by care providers, thereby standardizing and simplifying dilutions.7 Additional strategies include standardization of the practice of syringe labeling for both original and diluted versions. This practice of syringe labeling should be standardized and promoted in clinical practice as well as in training, such that these behaviors translate into independent, clinical practice.8
Best practices for drug preparation and drug dilution in anesthesia often overlap. Anesthesiology is a field in which multiple medications are handled and prepared by the same individual, creating room for error during drug preparation. Individual strategies for reducing these errors include optimization of the clinical environment, minimization of distractions, and consistent labeling to mitigate the likelihood of confusion during preparation and dilution. Systemic strategies largely depend upon institutional standardization of practices – including drug preparation and training – as well as upon the availability of drug preparations from drug manufacturers.
References
1. Sameera V, Bindra A, Rath GP. Human errors and their prevention in healthcare. J Anaesthesiol Clin Pharmacol. 2021;37(3):328-335. doi:10.4103/joacp.JOACP_364_19
2. Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews. Front Med. 2022;9:875426. doi:10.3389/fmed.2022.875426
3. Murphy BP, Sivaratnam G, Wong J, Chung F, Abrishami A. Medication administration errors during general anesthesia – a systematic review of prospective studies. Published online March 29, 2023. doi:10.1101/2023.03.28.23287875
4. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2016;124(1):25-34. doi:10.1097/ALN.0000000000000904
5. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The Frequency and Nature of Drug Administration Error during Anaesthesia. Anaesth Intensive Care. 2001;29(5):494-500. doi:10.1177/0310057X0102900508
6. Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Educ. 2019;19(5):151-157. doi:10.1016/j.bjae.2019.01.001
7. Committee on Quality Management and Departmental Administration, American Society of Anesthesiologists. Statement on drug concentration standardization. Am Soc Anesthesiol. Published online October 23, 2019. https://www.asahq.org/standards-and-practice-parameters/statement-on-drug-concentration-standardization
8. Kinsella SM, Boaden B, El‐Ghazali S, et al. Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists. Anaesthesia. 2023;78(10):1285-1294. doi:10.1111/anae.16095
