Pharmacy Corner
RESOURCES FOR PHARMACY

“There is a lot of pressure on operating room anesthesiologists, who work in a fast pace and often tense OR (operating room) situation,” says Esther Fung. “There is no current process to double check that the anesthesiologist has not made an error in the preparation or administration of a drug. They are the only ones responsible for the drugs in the OR – they have no one else there to check them .”

Dr. Fedorko, an anesthesiologist at Toronto General Hospital, explains that the drug preparation process in most operating rooms is currently manually driven, and as such is prone to human error. “With poor visibility and multiple distractions, there is always a chance that the anesthesiologist could get drug vials mixed up or put the wrong label on a drug, with dire consequences.”

Administration of the correct drug presents another challenge. In some operating rooms there could be as many as 20 syringes beside the patient, all with hand-written labels.

It is estimated that as many as 7% of adult hospital patients will experience some kind of medication error during a hospital stay. That number increases to 12% in the case of children, where the administration of the correct drug concentration is much more complex.

“The induction of anesthesia constitutes the injection of lethal drugs, every time”, says Dr. Fedorko. “Essentially we take away the patient’s brain and muscle function. It is safe because we know how to administer these drugs. Nonetheless, an anesthesiologist administers about 10,000 doses per year, and even if the error rate is extremely low, each year an anesthesiologist can be expected to commit a certain number of errors.”

As Esther Fung says, “The manual drug handling process really needs an electronic double-check that helps to remove the element of human error. The purpose of our project was to develop a method that would improve safety, without incurring overly high operating costs or interfering with the anaesthesiologist’s workflow.”

The new anesthesiologist medication preparation workflow process ensures that all medications provided by the pharmacy to the operating room have a barcode on each unit-of-use package. An essential component of the process is the DuoCheck™, a device engineered by Thornhill Research Inc. of Toronto. The DuoCheck is capable of scanning high density barcodes on drug vials, calculating diluted concentrations, providing audible feedback to confirm the identity of the drug scanned, and generating accurate and legible syringe labels. During medication preparation, the anesthesiologist scans each drug vial to obtain a visual and audio confirmation of the medication before drawing it into a syringe. If the medication is correct, the anesthesiologist touches the device screen to generate a label, and then places the label on the syringe. Each label contains the medication name, its ASTM color code, the volume drawn into the syringe, diluted concentration, diluent, time of preparation, expiry date and a barcode with all this information. Just before administering the drug to the patient, the anesthesiologist scans the barcode on the syringe’s label to get an independent verification, via the visual and audio feedback, that the intended medication is being administered, thereby preventing potential syringe swap errors.

Esther Fung

Dr. Ludwik Federko

The DuoCheck