www.asamonitor.org 36 R “Read the label, read the label, read the label!” Anyone who has administered anesthesia has probably heard or said this phrase many times in their career. And nobody wants to cause harm. How effective is repeating this in preventing medication errors and harm from anesthesia? The corporatization of medicine and the financial drivers in today’s market, along with government mandates and the risk of CMS reimbursement penalties, are forcing hospitals to demand more safety, efficiency and harder work from their clinical staff. While there have been discernible improvements in the safety and quality of anesthetic care, patients still experience unacceptable harm. Patients often struggle to have their voices heard, processes are not as efficient as they could be and costs continue to rise at alarming rates while quality issues remain. 1 It’s now 40 years since Cooper and colleagues first described “syringe swaps” in 1978 as one of the top three causes of preventable anesthesia mishaps. 2 The authors identified human factors associated with these types of medication errors, including haste, inattention/carelessness, fatigue, distraction, and poor labeling and failure to check or read the label, among others. While progress has been made to address these human factors, 3 in some ways they haven’t gone away and their impact may even be more prevalent, given the surge of new and poorly designed technologies and EMRs. Some of our colleagues dispute which events should be reported and which are “just stuff that happens.” Nebeker et al. define a medication error as the inappropriate use of a drug that may or may not result in harm. 4 An adverse drug event is defined as harm caused by the inappropriate use of a drug. When a medication is used properly with a subsequent adverse outcome, it is known as an adverse drug reaction. Examples of common medication errors within the O.R. include incorrect dosage, incorrect medication and wrong site administration. 5 In one large, prospective study, the most common medication errors were labeling errors, wrong Lebron Cooper, M.D., FASA, is Professor of Anesthesiology, College of Medicine, University of Tennessee Health Science Center, Memphis. Paul Barach, M.D., M.P.H., is Clinical Professor, Wayne State University School of Medicine, Detroit. Sweeping It Under the Rug: Why Medication Safety Efforts Have Failed to Improve Care and Reduce Patient Harm Lebron Cooper, M.D., FASA Paul Barach, M.D., M.P.H. Committee on Patient Safety and Education Figure 1. Examples of medi- cation errors due to confusing, unintended interchange of drugs or look-alike vials. Drug mix-ups are among the most common reasons for anesthesia medication errors resulting in serious patient harm or death. Downloaded From: http://monitor.pubs.asahq.org/pdfaccess.ashx?url=/data/journals/asam/936952/ by Paul Barach on 05/06/2018