Rethinking Anesthesia Medication "Errors": The OR-SMART Patient Safety Learning Laboratory.

Area of Science:

• Patient Safety
• Systems Engineering
• Human Factors Engineering

Background:

• Anesthesia medication errors pose a significant patient safety challenge.
• A systems engineering approach is crucial for understanding and mitigating complex healthcare errors.

Purpose of the Study:

• To apply a systems engineering approach to reduce anesthesia medication errors.
• The Operating Room Systems-based Medication Administration error Reduction Team (OR-SMART) aimed to identify effective technologies and interventions.
• To study the anesthesia medication work system and its potential for error reduction.

Main Methods:

• A mixed-methods study conducted at two academic medical centers (Johns Hopkins and MUSC).
• Utilized diverse data sources including interviews, observations (video-based), databases, and incident reports.
• Employed the Systems Engineering Initiative for Patient Safety (SEIPS) framework to model medication processes.

Main Results:

• Identified medication icon labels, a syringe holder hub, and workspace design guidelines as key interventions.
• Medication label icons demonstrated significant benefits in simulation and practice.
• Workspace design improvements, evaluated via virtual reality, subjectively enhanced situational awareness and available workspace.

Conclusions:

• Systems engineering and human factors principles can effectively identify interventions to reduce medication errors.
• Specific interventions like improved labeling and workspace design show potential for enhancing OR safety.
• Further development and testing of identified interventions are warranted to optimize patient safety in anesthesia medication administration.