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CPSI Share                                              
6/28/2011 6:00 PM

​​Esther Fung, Director of Pharmacy Operations and Drs. Ludwik Fedorko, Joseph Fisher and Rita Katznelson, researchers and anaesthesiologists with the University Health Network (UHN) in Toronto, Ontario were recently awarded the Ian White Patient Safety Award for Best Paper in Patient Safety by the Canadian Anesthesiologists' Society (CAS). The award, presented at the CAS annual conference in June, was given in recognition of their work on a point-of-care barcode aided medication process for anesthesia caregivers. The process helps to verify ampoule dispensation, produce accurate syringe labels and aid verification of each syringe prior to administration. This research project was partially funded by the Canadian Patient Safety Institute in 2008.

“We are honoured to be recognized by our peers for this economical solution to improve medication safety in operating rooms across Canada,” says Esther Fung.  “The medication bar-coding system recognizes the vigilance required by anaesthesiologists to ensure proper administration of medications in the operating room and incorporates safety factors that will reduce the risk of errors.”  

This Pharmacy and Anesthesia collaborative project was implemented in all 20 operating rooms at the Toronto General Hospital (one of the three hospitals that form the UHN) in January 2010. Previously, medications were provided to the operating rooms through a tray exchange and stock replenishment process.  Medications were not in a patient-specific, unit-dose, ready to be administered format. Within two weeks of implementation, all of the hospital’s anaesthesiologists voluntarily adopted the new process. After 18 months, over 134,000 medications were dispensed for over 12,000 cases using the new process and no medication identification error incidents were reported.

The bar-coding system provides accurate syringe labelling and independent ampoule/syringe verification throughout the dispensation, premixing, administration and documentation process. The process was designed to enable real-time documentation of medications, fluids, infusions and urine, blood loss with the use of touchpad like monitor user interface. The design reduces interactions with the computer to an absolute minimum and makes computer data entry easier and faster than manual paper reporting.  Electronic anesthesia monitor data capture was also incorporated to produce an intra-operative record. 

“Safe drug administration and independent verification and appropriate labelling of high risk drugs are compromised every day because of the lack of available and cost-effective solutions,” says Dr. Fedorko.  “The barcode aided medication verification process is a safe and effective way to intercept and prevent potential medication errors during anesthesia. It can be easily and economically implemented in any size surgical facility, across a variety of surgical procedures and in a large volume of patients.”

The research report, A Point of Care Mediation Bar-Coding System in Operating Rooms for Drug Dispensing, Labeling, and Administration Verification during Anesthesia, is available on the Canadian Patient Safety Institute website.