Medication error in operating room: Pardonable or perilous?

Sir, In a world where doctors are considered divine not just for saving lives but also to be able to work indefinitely, patient safety becomes paramount. Anesthesiology is not just a leading branch in patient management; it is also becoming one of the top branches with the most burnt-out, stressed, and overworked doctors.[1] This high-stress environment, compounded by prolonged working hours and cognitive overload, significantly increases the risk of human errors. Any human error in the operating room (OR), particularly related to drugs like the administration of the wrong drug/route/dose, can result in increased morbidity and costs associated with health care. After taking informed consent, a 32-year-old male, American Society of Anesthesiologists II, posted for inguinal hernioplasty had bradycardia postsubarachnoid block. On administering “injection atropine,” the patient had tachycardia (180 bpm), high blood pressure (200 / 106 mmHg), and severe headache, pointing toward accidental administration of adrenaline instead of atropine. This incident underscores how “Look-Alike Sound-Alike” (LASA) medications can lead to serious adverse events if proper safeguards are not in place. This inadvertent drug error was detected after searching for the used ampoules. The patient was successfully managed and settled. Paracetamol 1 g and midazolam 1 mg were administered to reduce the pain and anxiety and sedate the patient. This event raised the question of reasons for such human error and plausible ways to ensure patient safety. In the scenario presented to us, the lack of closed-loop communication, overworked team, similar-looking 1 ml ampoules kept together in the crash cart (LASA drugs), improperly labeled syringes, urgency, and distractions caused by background chatter and movement of staff might have been the factors leading to the mishap. According to the Human Factors Analysis and Classification System, such errors can be attributed to multiple layers including organizational influences, unsafe supervision, preconditions for unsafe acts, and the unsafe acts themselves.[2] Recognizing and addressing them are essential for preventing future errors. However, such distractions must be avoided during critical phases like administering an emergency drug, especially vasoactive drugs, during induction of anesthesia, and extubation. Implementing strategies such as standardized protocols, double-check procedures, dedicated storage spaces for high-risk medications, and the use of bar-coded medication administration systems can significantly reduce the likelihood of medication errors.[3] Additionally, the “International Colour Coding System” has been implemented to establish a standard background color for the labels of syringes prepared by the individual who would administer the drug[4] [Figure 1]. Adopting mnemonics like “SAFE-LABEL CHECK” can aid in ensuring correct medication administration.[5]Figure 1: Different background color coding of the drug’s labelFurthermore, it is important to stay vigilant, minimize distractions, ensure closed-loop communication (read-back policy while administering drugs), close check on duty hours, structured calm response to stress, and follow each step in the OR with a hawk-eye for patient and doctor safety. Creating a culture that encourages reporting and analysis of errors without blame can contribute to continuous improvement in patient safety. To conclude, “Anaesthesia is not only an art but also a state of mind,” and therefore, the OR should function with each procedure as a dance of teamwork for the best possible outcome for the patient. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.