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

We combine the results of multiple studies to describe a systems engineering approach to a well-recognized patient safety problem. The goal of the Operating Room Systems-based Medication Administration error Reduction Team (OR-SMART) patient safety learning laboratory was to study the anesthesia medication work system to identify the characteristics of technologies and interventions that might feasibly reduce anesthesia medication errors.

The work was conducted at 2 large urban academic medical centers: Johns Hopkins and the Medical University of South Carolina. We sampled across many different types of anesthesia work, understanding the challenges of work-as-done, and applying systems safety principles and evaluation frameworks.

This was a mixed-methods study. Sources of data varied, with formal and informal interviews, formal and informal observations, video-based observations, hospital and national databases, and information from local incidents. Clinically embedded human factors professionals at both hospital sites facilitated informal sources of data. We explored the variable definitions of error; individual and organizational variability in decision-making; how syringes are used, stored, and moved within an operating room (OR); and used the Systems Engineering Initiative for Patient Safety framework to model medication processes. We were able to identify more than 100 possible interventions, and then prioritized a few for development and testing.

We identified medication icon labels, a syringe holder hub, and workspace design guidelines as interventions for evaluation. Significant benefits of medication label icons were found in simulation and were highly utilized in practice. The syringe hub demonstrated high acceptability at one site but substantially less at another. A virtual reality-based evaluation of the OR design found that situational awareness, visual monitoring, and available workspace were subjectively improved.