Process Risks in Perioperative Medication Delivery

One anesthesia provider is often responsible for prescribing, formulating, dispensing, administering, and documenting medications in the operating room. Unlike other hospital units, there are few safety interventions. Systems engineering approaches can provide important insights into improving patient safety during medication delivery processes (Kaplan et al., 2013; Reid et al., 2005). This study observed anesthesia medication delivery during 20 anesthetic cases in the OR and interviewed 10 anesthesia providers in a large midatlantic academic hospital using a Systems Engineering Initiative for Patient Safety (SEIPS) framework to identify process risk in perioperative medication delivery (Holden et al., 2013). Anesthesia attendings, fellows, residents, and certified resident nurse anesthetists (CRNAs) were sampled based on who was in the OR during observations and who volunteered for interviews. Interviews were transcribed and coded through a consensus procedure. The medication delivery process was described using a SEIPS-based process map. Tasks were separated based on the anesthesia phase, though the tasks and phases are not linear; e.g: a provider may prepare for the next case during the maintenance phase.