APSF developed a new paradigm based on 3 principles:standardization, technology, and prefilled or premixed medications.These principles emphasize not only areas in which safety has been lacking but also opportunities for growth and development.Standardization of High-Alert Medications.Medications such as phenylephrine or ephedrine should be prepared by a pharmacy to ensure that the syringes and infusions have a standardized concentration and label When prepared by anesthetists, high-alert drugs can be prepared in different strengths depending on
provider preference, and this practice can easily result in administration errors, especially when a second provider administers the drug. The standardization of high-alert medications will eliminate the potential for error when diluting and preparing medications and will increase the
safety of the patients and staff.Standardization of Workspace. Standardization also
refers to the anesthesia workspace in terms of the arrangement
of the medications and equipment. Organizing drug trays to eliminate the proximity of sound-alike or look-alike medications will help decrease the number of ADEs. The removal of rarely used medications from the workspace will help reduce the potential to prepare and
administer the wrong medication. A pharmacy located in the surgical area can be beneficial in developing and maintaining medication trays and in dispensing the less common medications.The sterile preparation of medications by the pharmacy is standard in inpatient units and is a standard of the Joint Commission, but this standard is not strictly adhered to in surgical areas.Furthermore, the APSF recommends the elimination of provider-prepared medications whenever possible and the use of pre-prepared kits or drug trays whenever possible.These standardizations will result in universally used dilutions and concentrations of high-alert medications and will help reduce the number of wasted medications that are prepared and never used.Standardization of Technology. Along with the standardization
of high-alert medications and workstations,
the standardization of the technology used will also
help reduce the number of adverse events. Electronic
health records are widely used in operating rooms, but
the full potential of using these systems in medication
administration has not been fully realized. The APSF
recommends using BCMA because it provides visual and
auditory feedback that can assist anesthesia providers in
delivering safer care. Just as intraoperative monitoring
has changed the safety of anesthesia, BCMA can help
reduce morbidity and mortality caused by ADEs.Systems for BCMA provide secondary verification of
the 6 rights of medication administration: right medication,route, time, patient, dosage, and documentation.The provider chooses a medication and scans the standardized barcode on the medication. The computer then voices the medication and concentration as a secondary verification for the anesthesia provider before the medicationis injected. Along with verifying the medication, the computer documents the administration of the medication in real time on the electronic anesthesia record,which further reduces the number of ADEs resulting from
inaccuracies in recording the medications administered.
Compliance and Cost of Barcode Medication
Administration
An increase in patient safety resulting from BCMA use is dependent on the provider’s use of the technology available. Alarms and limits on ventilators, intravenous pumps, and monitors are in place to protect the patients and assist the providers in delivering safe anesthetics.
These types of alarms and limits are available in BCMA systems, but providers must acknowledge and use them to provide safer care. The rate of errors using BCMA is inversely proportional to compliance with system alarms.It has been shown that the number of ADEs decreases
when anesthetists adhere to the following principles of BCMA use: scanning each medication before administration,keeping the audible voice prompts enabled, and reacting to system warnings.
The use of BCMA and premixed or prefilled syringes in the operating room may increase costs during the initial implementation phase, depending on the facility’s technology and use of electronic health records, but will eventually generate savings in time, safety, and the documentation of medications administered.According to the IOM, approximately $2 billion is spent annually on ADEs in hospital settings. This amount does not reflect the costs associated with errors in outpatient and office settings or in hospitals that do not use electronic medical
records and data collection. If BCMA is not used in operating rooms, a pharmacy located in the surgical area would be beneficial in assisting with the preparation,dispensing, and inventory of medications. This type of setting, however, would require additional pharmacy staff.Systems for BCMA can accomplish all of these tasks and provide a means of communication between the pharmacy and anesthesia providers without needing a pharmacy representative in the surgical area.
Implementation. The initial cost for implementing BCMA depends on the technology infrastructure available in the facility and operating room (Figure 3).If a facility does not have electronic pharmacy management and patient medical record documentation in place, the cost will be greater because of the need to plan, staff,train, initiate, and monitor the implementation of a new
system.If a hospital is required to implement electronic pharmacy management and BCMA without any previous infrastructure in place that can be upgraded, the estimated cost is between $35,600 and $54,600 per BCMAenabled bed. This estimate includes system upgrades and hardware replacement.The cost potentially could be reduced by half or more if an electronic pharmacy management and electronic health record infrastructure is already in place.
On evaluating the cost of implementation, it is imperative to compare the cost of implementation with the cost of errors prevented because of BCMA use. It has been shown that BCMA prevents an average of 1.1% (range, 0.4% to 1.9%) of errors associated with medication administration.This value represents an operating cost of $2,000 per moderate to severe medication error
prevented. Compared with the amount proposed by the IOM that is spent on ADEs, $2,000 is a fraction of the total cost to healthcare consumers and facilities.A MEDMARX data report (Quantros Inc) found that as many as 81% of medication errors occur in the operating
room and postanesthesia care unit.This number of errors justifies the implementation of a BCMA system in surgical areas. Clearly, the initial cost of implementing a BCMA system is a large investment for any hospital, but the return on this investment in the form of a reduced
number of costly and potentially deadly ADEs is equally great, if not greater.