Anesthesia and Patient Safety: 5 Rights of Medication Administration

There is an ongoing effort within the healthcare industry to improve medication safety, and with good reason. The Office of Disease Prevention and Health Promotion shares some eye-opening statistics: In inpatient settings, adverse drug events (i.e., harm resulting from medication use) account for an estimated one in three of all hospital adverse events. They affect about 2 million hospital stays annually and prolong stays by 1.7 to 4.6 days. For outpatient settings, adverse drug events account for more than 3.5 million physician office visits, approximately 125,000 hospital admissions and an estimated 1 million emergency department visits[i].

All members of a clinical team, including anesthesia providers, have a responsibility to follow rules and strive to keep patients safe when administering medications. One method to help reduce medication errors is to follow the "five rights of medication administration[ii]."

Here's an overview of these five rights, their application in the operating room (OR), and the role technology, such as electronic anesthesia documentation and barcode scanning, can play in delivering safe, high-quality care.

1. Right patient

Confirming you have the correct patient in the OR is an early step, and many facilities choose to follow the Universal Protocol's surgical “time out” for accurately identifying the patient, surgical site, and planned procedure before surgery begins[iii].

Even though you are dealing with one patient at a time, it is important to ensure you have the right patient on the table and verify that the correct patient chart is pulled up in your electronic medical record and anesthesia documentation systems. 

2. Right drug

Out of the five rights, this is probably the one with the most implications for anesthesia providers. Most of the time, for anesthesia medications, providers pre-draw medications into syringes from vials before patients come into the OR. There are a number of requirements concerning the labeling of these medications, including the manner in which they are labeled and the information included on the label (e.g., type of medication, concentration, date and time of expiration).

There is the potential for several errors to occur during drug preparation and administration, including the risk of syringe swapping or inappropriate dosing due to improperly labeled drug concentration.

The use of barcode technology can help ensure the correct drug is delivered[iv]. Automated medication barcode printers can eliminate much of the manual work of labeling medications. Rather than putting a piece of tape on a syringe, scribbling information on it and hoping you can read it later, barcode scanners can print out a legible label with a barcode that can be scanned to pull up information on the drug.

Integration between the anesthesia documentation and barcode systems allows the technologies to work together for crosschecking drug interactions/contraindications and checking medications against the patient's documented allergies.

3. Right dosage

An incorrect dosage of a medication can have significant effects on a patient's wellbeing ranging from minor discomfort to significant harm. While this is true for all patients, knowing limits and warnings concerning dosage is particularly important in pediatrics where there are many patient weight-based rules.

Some electronic anesthesia documentation systems can provide upper limits for certain drugs based on a patient's weight. A comprehensive system should provide a summation of the total amount of medication delivered throughout the patient's episode of care to help providers keep track of how much medication they have administered.

With the increased legibility of an electronic documentation system, it is easier to read and track the drug dosages and cumulative amount delivered.

4. Right route

Most anesthesia drugs administered in the OR are delivered intravenously, so identifying the correct route should prove easier than in other settings. However, some medications, such as those that are more caustic, may need to be administered in central lines rather than peripheral lines. An anesthesia documentation system should integrate with a pharmaceutical management system to identify these drugs that may require specific routes of administration so providers can make the appropriate care decisions.

5. Right time 

This is another of the five rights that's slightly less applicable in the OR, but still critical. Knowing the right time for the initial dose should be relatively easy. What can prove more difficult is the timing of redosing, particularly for antibiotics used prophylactically to reduce the risk of a surgical site infection. An ideal electronic anesthesia documentation system would provide information regarding medication redosing intervals to ensure the appropriate guidelines are followed.

Some organizations struggle with documenting accurate drug administration time. The reason: Providers may deliver the drug and then document it several minutes later, estimating the time when administration occurred. Some barcode systems now provide near-real-time documentation, which includes the time a drug was administered rather than when the providers are retrospectively "estimating" the time.

[i] Adverse Drug Events, health.gov, https://health.gov/hcq/ade.asp, accessed 08/06/2018

[ii] The Five Rights of Medication Administration, Institute for Healthcare Improvement, http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.aspx, accessed 08/06/2018

[iii] The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™, The Joint Commission, https://www.jointcommission.org/assets/1/18/UP_Poster.pdf, accessed 08/06/2018

[iv] Factsheet: Bar Code Medication Administration, The Leapfrog Group, https://www.leapfroggroup.org/sites/default/files/Files/2018%20BCMA%20Fact%20Sheet.pdf, accessed 08/06/2018