Anesthesia Medication Handling Needs a New Vision

Eliot B. Grigg, MD; Axel Roesler, PhD


Anesth Analg. 2018;126(1):346-350. 

In This Article

The Problem

Anesthesiology may be "widely recognized as the pioneering leader in patient safety efforts" but not because of medication safety.[1] The Anesthesia Patient Safety Foundation, the Closed Claims Project, and the myriad engineering improvements to the anesthesia machine in the past 30+ years are all laudable. Pioneering work in critical incident analysis in the 1970s led to many improvements to prevent airway- and ventilation-related mishaps—the leading cause of morbidity at the time.[2] Monitoring patients (with pulse oximetry and capnography), managing airways (with difficult airway algorithms and video laryngoscopes), and simulation training are impressive advances. However, despite being identified as a significant source of adverse events, the other side of the anesthesia workspace—intravenous (IV) medications—has proven more challenging to improve due to medications that are less tolerant of mistakes than inhaled agents and a more complex provider workflow. Consequently, the anesthesia approach to IV agents remains remarkably primitive, fragmented, and cavalier:

  1. We do not know the true prevalence of medication errors.

  2. Dangerous myths persist in our specialty.

  3. Little prevents providers from making basic errors.

  4. An entrenched resistance to standardization prevents advances.

Single-point failures—rarely tolerated on the anesthesia machine—are rampant with IV medications, and most error prevention relies on brittle strategies like "provider vigilance" and "reading the label." Recommendations as recent as this past year still include stipulations like "syringes should be labeled" (with some exceptions)—an indication of how low expectations are in the medication sphere.[3] If a bottle of volatile anesthetic was unlabeled, we would never administer it to a patient. An opportunity exists to learn from advances on the anesthesia machine, question assumptions about the IV medication space, and reaffirm our specialty as pioneers in patient safety.