In the preceding letters, Parr, Schroeder, and colleagues describe medication error events that resulted from look-alike medications and complicated medication labels. These reports evoke the familiar emotions of frustration, empathy, and intolerance, because as anesthesia practice has become increasingly safer throughout the years, we have unintentionally allowed preventable medication errors to remain commonplace. One recent report has estimated that medication errors occur in 1 out of 20 medications administered.1 This relatively high incidence continues despite the awareness highlighted by the Institute of Medicine’s Report To Err is Human in 2000.2
As anesthesia professionals, we have a responsibility to demand safer medication labeling strategies and are primed to lead this change. As a public health framework to emulate, a unique parallel situation exists for improvements of nutrition labeling on commercially prepared foods to protect individuals. The growing desire of Americans to better understand the components of the food they consume compelled the Food and Drug Administration to implement a regulatory framework for food labeling based on the belief that smarter dietary choices would decrease the leading causes of death (i.e., heart disease, cancers, strokes, and diabetes).3,4 Ultimately, it was the voice of the American consumer, guided by the health care community and scientific evidence, that resulted in the standardization and simplification of nutrition labeling in the form of a “Nutritional Facts” panel now found on most commercially packaged foods.
Improved clarity in communication through regulation is an example of using data-driven health care policy that is likely to improve health and safety. No one expected standardized nutrition labels to cure heart disease; however, it was important to support consumers in making smart dietary decisions. Similarly, compulsory medication labeling will not entirely prevent anesthesia personnel from making errors, but it will help them proactively recognize when an error may occur. Anesthesia professionals should not have to read between the lines on the drug vial or syringe when practicing in a complex and highly stressful clinical environment. We should be able to confidently select a local anesthetic with epinephrine from our drug tray and know that it is safe to use because we have selected a product with clear labeling that states “For Neuraxial Use Only.” The next generation of anesthesia-based electronic records should contain bar-coding modules to decrease medication errors even further.5
We thank Parr and Schroeder and their colleagues for sharing these important events that emphasize that unless we advocate for safer systems these errors will not disappear. Like the nutrition labeling initiatives of the 1990s, it is time that we demand change and work with key regulatory stakeholders in the area of public health law6 to standardize safer drug labeling methods, as well as improve the availability of prefilled syringes to help prevent vial swap, and bar-coding techniques to help prevent syringe swap.
Dr. Lobaugh is assistant professor in the Department of Anesthesiology, Perioperative, and Pain Medicine, Baylor College of Medicine.
Dr. Litman is professor of Anesthesiology and Pediatrics at the Perelman School of Medicine at the University of Pennsylvania and an attending anesthesiologist at the Children’s Hospital of Philadelphia.
Dr. Lobaugh has no conflicts as they relate to this article. Dr. Litman serves as medical director for the Institute for Safe Medication Practices.
- Nanji KC, Patel A, Shaikh S, et al. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124:25–34.
- Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safe health system. Washington, DC, National Academy Press, 2000.
- Harper AE. The surgeon general’s report on nutrition and health: summary and recommendations. JAMA. 1989;262:
- National Research Council (US) Committee on Diet and Health. Diet and health: implications for reducing chronic disease risk. Washington (DC): National Academies Press (US); 1989. Available from: https://www.ncbi.nlm.nih.gov/books/NBK218743 Accessed August 8, 2019.
- Litman RS. How to prevent medication errors in the operating room? Take away the human factor. Br J Anaesth. 2018;120:438–440.
- Litman, RS. Use of a public health law framework to improve medication safety by anesthesia providers. J Pat Safety Risk Management 2019. https://journals.sagepub.com/doi/abs/10.1177/2516043518825383 Accessed August 8, 2019.