Anesthesia Drug Safety

Our story of improving anesthesia drug safety started in early 2000's and continues today . . .

Data from American Society of Anesthesiologists Closed Claims Project Database comparing the drug error rates from 1980-1997 (published by Dr. Bowdle in 2003) to 2000-2012 (courtesy of Dr. Karen Domino) show that the substitution errors continue to be major contributor to anesthesia drug errors.

Injectable drugs are the predominant route of drug administration in anesthesia care, which is prone to errors. Because there are many different types of errors including substitutions, incorrect dose, omissions and insertions with different mechanisms, there is no single solution to this problem. Substitutions are one of the most common types of anesthesia drug errors which include vial and syringe swaps. Interestingly, vial swap error was portrayed in the recently released movie "Knives Out" where similar-looking vials of ketorolac and morphine were swapped. A well-known vial swap error involving Dennis Quaid newborn twins was extensively covered by the media in 2007 when a 1,000-times higher dose of heparin was administered due to mistakenly drawing the drug from a higher concentration vial. 

Our efforts in addressing anesthesia drug errors were inspired by Dr. Alan Merry, who is the world's expert on anesthesia drug safety and the creator of SAFERsleep. We have spent the last 15 years designing, implementing, and studying a variety of interventions to prevent anesthesia drug errors. The timeline below summarizes our efforts.

One of our early efforts in preventing syringe swaps involved colored syringe plungers for pharmacy prepared high risk drugs such as epinephrine and succinylcholine and plunger flags for commercially prefilled medications to alert providers and prevent syringe swaps. 

Anesthesia Drug Safety System

We took a uniquely innovative approach to barcode scanning of drugs in anesthesia practice. We combined a commercially available syringe label printer (Codonics Safe Label System) with a hand-held bar code reader and our decision support software, Smart Anesthesia Manager. The Codonics label printer is intended to prevent vial swaps which is when providers misidentify vials and administer the wrong drug. The Codonics label printer scans the barcodes on drug vial, speaks the name of the drug and prints a Joint Commission compliant syringe label. The second part of our system is intended to prevent syringe swaps. The provider scans the barcode on the syringe label prior to medication administration while the system provides visual and auditory confirmation of the correct medication and concentration. Smart Anesthesia Manager speaks the name of the drug and displays the name of the drug along with a field for manually entering the dose in the anesthesia electronic record. Smart Anesthesia Manager is a unique anesthesia decision support software that we created, which functions in conjunction with our anesthesia electronic record. The barcode scan is date and time stamped which can be used for auditing purposes.

After the implementation of the anesthesia barcode-based safety system at all anesthetizing locations, we randomly audited about 2,000 anesthesia syringes. There was 99% compliance with syringe labeling indicating a wide adoption of the Codonics syringe labeling system. There were only a few hand-labeled and unlabeled syringes. The adoption of the syringe label was extremely successful and did not require additional measures to change provider behavior. However, improving compliance with syringe barcode scanning prior to medication administration was a much bigger challenge. The baseline compliance was around 10% for the first 17 months.

We decided to implement a behavior modification bundle that consisted of provider education, monthly performance reports sent by email to individual providers along with coffee gift card awards for top performers. The coffee gift cards were awarded in only the first two months of the intervention while the email performance reports continued every month. Following the implementation of the behavior modification bundle, the syringe barcode scanning performance significantly improved to an average of around 65% for the next seven months. Our unique performance feedback was a combination of public and private feedback. Individual providers were shown their performance relative to other providers but did not know the identity of the other providers while coffee card recipients were publicly announced via group email. 

During 10 months of baseline drug error data collection, there were about 15,000 cases and 57 errors (0.39%) reported including 5 vial swaps and 1 syringe swap. Following the implementation of the barcode-based safety system, we collected another 25,000 cases over 13 months and 54 errors (0.23%) including 0 vial swap errors and 2 syringe swap errors. The 41% reduction in errors was highly statistically significant (p=0.0045). The reduction in vial swap errors was statistically significant (p=0.004), while there was no statistically significant difference in syringe swap errors.


In recognition of our efforts to improve anesthesia medication safety through novel anesthesia drug safety system design, successful implementation, and improved patient outcomes, we received a best practice for safe medication administration during anesthesia care award by the Anesthesia Patient Safety Foundation in 2018.


Br J Anaesth. 2018 Dec;121(6):1338-13455.

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