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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. Methods: This project took place in three phases. In the Evaluation phase, evidence-based literature on anesthesia medication safety practices were evaluated, and high-risk/ look-alike, sound-alike medications on anesthesia medication trays were identified. In the Standardization phase, the interdisciplinary team developed strategies to organize the medication trays to improve safety. These standardized strategies were executed throughout the anesthesia mediation trays in the final Implementation phase. Results: A total of eight-three changes were made to the anesthesia medication trays. Sixty medications were removed, with an average of ten removals per tray. High risk medications were replaced with unit-of-use or ready-to-use syringes when possible, with an average of four replacements per tray. The greatest number of medication tray changes was in the trauma operating suite with a total of twenty-eight. Conclusions: Numerous opportunities were identified to decrease the potential for human error by standardizing anesthesia medication trays with a focus on optimizing medication safety. Organization and standardization of anesthesia medication trays is an economical strategy to decrease opportunity for human error in the operating suite that requires minimal capital outlay. Although previous studies have recommended strategies and technologies to improve medication safety in the operating suites; these interventions have yet to be implemented. Our unique study demonstrates successful intervention implementation.

Interdisciplinary Anesthesia Tray Revision Project: Reducing the Opportunity for Human Error