In an attempt to improve patient safety in the operating room, a consensus conference convened by the Anesthesia Patient Safety Foundation has produced a series of recommendations that could eventually alter how perioperative anesthesia is conducted.

Studies have indicated there is one anesthetic medication error in every 133 drugs administered. One in 250 of those errors is fatal. As a result, nearly 1,000 people die in the United States each year from anesthesia medication mistakes.

The hope is that implementing these new standards will avert dangerous errors in the future. But the campaign to improve on these numbers might require some sacrifices from anesthesiologists.

“Anesthesia providers, at the head of the table in the OR, are going to need to surrender some of their traditional, well-protected autonomy,” said John Eichhorn, MD, professor of anesthesiology at the University of Kentucky, in Lexington, and consultant to the executive committee of the APSF board of directors. “The only way to really help prevent some of these errors is for other people and other systems to be involved in the process. There has to be a significant departure from traditions, and traditions are very hard to change.”

The recommendations come from a conference, held in January in Phoenix, that included 100 stakeholders from various ends of the health care spectrum. The participants proposed a new paradigm for improving medication safety in the OR, including four specific parts: standardization, technology, pharmacy/prefilled/premixed and culture.

Dr. Eichhorn, who wrote the report on the conference, said a video likely will be produced for educational purposes on some of the recommendations. Next steps toward implementation largely involve getting the message out on which areas of medication practice in the operating suite need improvement. If anesthesia and pharmacy directors, along with OR administrators, collectively approach hospital officials with the call for improvements, it could help the push to improve patient care, he said.

Putting Pharmacists in the OR

Among the recommendations is that hospital pharmacists should become more involved with dispensing medications in the OR. Satellite pharmacies with presences in the OR have already begun to spring up in larger institutions, but practices are not standardized, and most smaller hospitals do not employ this approach. To change this, the report suggested that enhanced training of pharmacists who work exclusively in ORs as “perioperative consultants” would provide an additional layer of checks and balances to anesthesia practice.

“Anesthesiology is genuinely unique in that we’re the only health care professionals who prescribe, compound, dispense and administer medications all in one continuous process, in real time, and sometimes in a matter of less than a minute,” Dr. Eichhorn said. By putting more people in the OR who are responsible for parts of that process and who can double-check doses and medications and other factors, the potential for error is reduced.

A potential barrier to the addition of OR pharmacists, however, is the culture anesthesia professionals have developed over many years.

“People do things the way they do them for a reason; it’s their comfort zone,” said Philip J. Schneider, RPh, associate dean of the University of Arizona College of Pharmacy, in Phoenix. “This adds additional steps into the system. It may result in loss of autonomy and professional judgment, so I’m quite certain that it will be challenging to do.”

Jerry Cohen, MD, of the University of Florida College of Medicine in Gainesville, and the first vice president of the American Society of Anesthesiologists, who participated in the conference and supports its conclusions, said that cultural barrier will not be the primary obstacle to change.

“Any group of specialists tends to resist change,” Dr. Cohen said. “But when objective evidence that a better way of doing things comes along, we’re going to do it. We don’t really spend a lot of time figuring out ways not to change.”

Standardization And Technology

Aside from adding layers of human checks and balances to OR anesthesia, the recommendations call for standardizing practices to reduce errors. For example, high-alert drugs including phenylephrine and epinephrine should be readily available in pharmacy- prepared concentrations. The increased use of technology also comes into play in these situations, with electronically controlled devices used to manage infusions.

Other ways of standardizing safety include keeping any concentrated versions of potentially lethal drugs out of the OR entirely; placement of drugs in an OR at set locations; implementing consistent infusion libraries and protocols throughout individual institutions; and having standard route- specific tubing connectors.

The key technology recommendation involves bar coding all medications, and having each anesthesia location carry a bar-code reader to ensure proper drug and dosing for patients. Technology training and device education could also be built in, with the possibility of requiring formal certification for users.

“We can’t afford to have old-style thinking anymore, and it’s time to bring this, like so many other things, into the modern era,” Dr. Eichhorn told Anesthesiology News.

Assessing the Costs

Aside from the barriers based on tradition and culture that may arise, Dr. Eichhorn said costs—in terms of workforce and technology—may cause some hospitals to balk at implementing the recommendations. Unfortunately, he said, it often takes a catastrophic error before institutions take measures to improve safety.

“Unless they have personally experienced it, they don’t believe you, that years’ worth of incremental costs to do this is less than a single event that leads to a lawsuit,” Dr. Eichhorn said. “Why does it have to take these accidents to provoke change?”

Although it may be intuitive that measures like adding a pharmacist to the OR would reduce errors and therefore long-term costs, Dr. Cohen said, the real impetus for changing practices will be data on those costs.

“It is possible that it’s a cost; it’s possible that it’s a savings,” Dr. Cohen said. “The only way we’re going to figure that out is with massive amounts of aggregated data. It is unlikely we will have randomized controlled trials on this.”

Dr. Cohen noted that databases like those maintained by the Anesthesia Quality Institute will soon start to provide the sort of data that could point health care professionals toward true cost-saving measures and safety improvements.