Decreasing Perioperative Medication Errors with Standardized Labeling Education

BACKGROUND: Medication errors are prevalent within the perioperative setting (Wahr et al., 2017). The anesthesia provider is the sole professional in charge of the medication process in the operating room, which results in fewer safety checks than in other healthcare settings (Nanji et al., 2016).

LOCAL PROBLEM: The proposed scholarly project aimed to reduce medication errors at an academic medical center in the Southeast using an educational module focused on standardized narcotic syringe labeling. The participants were anesthesia providers in the operating room at the project site.

METHODS: The Evidence-Based Practice Improvement model was used to guide the development, implementation, and evaluation of the scholarly project.

INTERVENTIONS: The project team used an education module created by the Phase I team and disseminated the module to the project participants in three Plan-Do-Study-Act cycles. The outcomes of the project were assessed by counting properly labeled fentanyl and hydromorphone syringes pre-and post-intervention.

RESULTS: Data was analyzed and evaluated through the International Business Machines Corporation’s Statistical Package for the Social Sciences Version 29 software application using Chi-Square tests to evaluate for statistical significance. Statistically significant improvements in standardized narcotic syringe labeling were found after implementation. Results showed statistically significant increases in patient and fentanyl concentration labeling compliance. Statistically significant increases in hydromorphone patient labeling compliance also occurred. There was no change in hydromorphone concentration labeling because the syringes were prefilled.

CONCLUSION: Improving standardized narcotic syringe labeling led to a reduction in medication errors. Recommendations for sustainability include continued surveillance of syringe labeling compliance by the pharmacy department, including the educational module as a yearly education requirement, and continued communication of compliance rates with anesthesia providers.