At the American Society of Health-System Pharmacists’ December 2011 meeting, one anesthesiologist from the University Health Network’s Toronto General Hospital in Canada described the operating room as a “black hole of medication safety.” He then went on to share the details of a pilot program at one hospital that involves having anesthesiologists scan bar codes on all medications before administration, which reportedly has been remarkably successful in reducing medication errors. One hopes that hospitals and anesthesiologists in Massachusetts and around the U.S. will note the results of the program.
The bar code scanning program at UHN began due to recognition that anesthesiologists are the only health care workers who dispense, mix, label and administer medication in the hospital without having a way of independently verifying the accuracy of the medication and dosage. Anesthesiologists at UHN partnered with the Canadian Patient Safety Institute to develop a system where anesthesiologists scanned every drug and syringe for accuracy through every stage of the dispensing, mixing and administration process.
UHN implemented the system in all 20 of the operating rooms at its Toronto facility in January 2010. After five months, the system had documented 60,000 doses in more than 4,000 surgeries. UHN administered an anonymous survey at that point to determine anesthesiologists’ satisfaction with the system and the errors that the system had prevented. Survey respondents reported a 97 percent satisfaction rate with the bar code scanning and 29 errors that the system prevented.
The hospital kept the system in place after the test period ended and has reported no errors when anesthesiologists scan medication bar codes. The hospital had one medication error during that period, when an anesthesiologist bypassed the scanning system.
Due to the fast pace of the operating room, it is important that anesthesiologists have some way of double checking that they are administering the proper dosage of medications. The code scanning program at UHN Toronto offers one potential solution to the problem of anesthesia errors in the operating room.
Source: Anesthesiology News, “Bar-Code Scanning Can Fix ‘Black Hole’ of OR Drug Safety,” Steve Frandzel, Jan. 2012