One thing we talked about towards the end of today’s session was our fears as clinicians and how for many of us our number one fear is making a mistake that could cause harm to a patient. As an anesthesia resident, I am constantly worried about this. Much of what we do in the OR is not double or triple checked by another clinician. For every drug given to a patient, we are the prescriber, pharmacist, and administrant. We are often tasked with having to give multiple drugs in a very short amount of time, and the thought of giving the wrong medication or the wrong dose is an easy one to imagine. On top of it, we have many medications that look very similar on their vial. For the most part, medications are color-coded to help prevent mistakes, but there are still errors in this setup. For instance, 4mg of zofran and 200mcg of precedex both come in blue 2ml vials and look almost identical except for the small writing on the side. I have even seen medication trays set up where these two medications are organized side-by-side. Another example includes the bristol jet syringes of 1mg epinephrine and 1g calcium that we have in the OR. Once out of their box packaging the syringes look almost identical. These are all drugs that if confused for one another could absolutely cause harm to our patients, if not death. The fact that some of these drugs are used in emergent situations causes me more fear because I believe the hurried nature of any emergent situation in the hospital leads to human error. These are fears that I have heard other anesthesiologists talk about yet nothing has changed in this design. The answer seems to always be that we should be more diligent in ensuring we are administering the proper medication in the proper amount. As we discuss what we can do as clinicians to improve safety in our hospitals this is something I will definitely focus on when I return and try to push our pharmacy department and leadership to come up with better solutions that will help prevent these sorts of errors.
