Dispensing Meds for Surgeries

Many patients in your hospital will require some sort of procedure, often one that requires them to go into an operating room or “OR.” These can range from simple and short procedures such as placement of an IV line or cleaning out a wound, to major surgeries on the brain or heart. Patients can receive a lot of meds in a short period of time during surgeries, and they’re at an especially high risk of experiencing med errors. In fact, it has been suggested that med errors occur in about 50% of surgeries. Some reasons for this include the fact that the workflow is fast-paced and very different from that for other patient care units, and checks and balances for meds can also be very different. Most med errors in surgery patients are preventable. There’s been a big push from groups, such as Joint Commission, to take steps to reduce the risk of errors in operating rooms. This technician tutorial will cover basic information about med use in operating rooms, along with tips for improving patient safety.

What are the different kinds of meds used during surgeries?

There is actually a vast number of meds used during surgeries, due largely to the fact that there are so many different kinds of surgeries. Following are some of the most common.

During most surgeries, patients will receive either local or general anesthesia. Local anesthesia involves injection of an anesthetic (e.g., bupivacaine, lidocaine, ropivacaine) into a specific area of the body. Sometimes local anesthetics will be given by epidural infusion or injection, into a specific location in the spinal column, in order to provide anesthesia to a specific part of the body. An example of this is when an epidural is used for a woman delivering a baby. General anesthesia, on the other hand, is what we think of as being “put to sleep.” General anesthesia involves the use of gases for inhalation, such as desflurane, isoflurane, or sevoflurane, or injectable anesthetics such as etomidate, ketamine, propofol, or thiopental. The goals of general anesthesia include preventing the patient from remembering the procedure or surgery, helping them to stay still, and keeping them unconscious. Injectable benzodiazepines (e.g., midazolam, diazepam, lorazepam) may be given along with anesthetics to add to their effects.

Patients also need to receive meds to provide pain control, or analgesia, during surgeries. This is most often done using injectable opioids such as fentanyl, hydromorphone, or morphine. Usually analgesics are given by IV push or infusion, but they may also be given by epidural injection or infusion in some cases. This is why you’ll see preservative-free versions of some opioids available to be used in operating rooms. Versions with preservatives cannot be given by the epidural route, due to the risk of toxicity from the preservative.

Another important type of med used during surgeries is a neuromuscular blocker, or paralyzing agent. Some patients will require intubation during surgeries, and they’ll need to be relaxed and still for the ventilator to help them breathe properly. Paralyzing agents used for surgery patients include cisatracurium (Nimbex, etc), rocuronium (Zemuron, etc), succinylcholine (Anectine, Quelicin, etc), and vecuronium.

Meds may also be needed to help patients maintain their vital signs, such as blood pressure and heart rate, during surgery. This is often done using infusions of vasoactive meds: vasopressors, such as epinephrine, phenylephrine, or norepinephrine, that keep the blood pressure and possibly the heart rate up; and vasodilators, such as nitroglycerin or nitroprusside, that help bring the blood pressure down.

Sometimes meds are needed to help stop bleeding, when other methods such as suturing (i.e., stitches) aren’t adequate. The most common meds used to stop bleeding are topical hemostats. These come in a variety of dosage forms, from powders to vials to sponges. Some commonly used brands include Evithrom, Gelfoam, and Tisseel. They typically contain substances that are naturally found in the body to stimulate clots, such as fibrin and/or thrombin. Tranexamic acid is an injectable med that can help stop bleeding. It does this by preventing the breakdown of clots that are forming.

Many patients undergoing procedures or surgeries will need to get antibiotics, to help prevent surgical site infections. Surgical site infections can happen when bacteria are transferred from one part of the body to another during a procedure, such as from the surface of the skin into an incision in the abdomen. Cefazolin is a very common choice, since it is effective against skin organisms. But you’ll also see other antibiotics used, depending on the procedure, such as vancomycin or clindamycin. There are two important things to note about perioperative antibiotics. One is that doses of cefazolin may be higher than you are used to seeing. Most adult patients should receive 2 grams, and some heavier patients will even receive 3 grams. The other is that timing is very important. Doses should be given within one hour prior to incision, then at intervals during surgery, depending on the antibiotic and the length of the procedure. Giving these extra doses helps keep blood levels of the antibiotic up, and your hospital likely has guidance on this.

Many patients will require “reversal agents,” which reverse the effects of anesthetics and analgesics, so the patient regains consciousness after a procedure or surgery is over. These include naloxone for opioids, flumazenil for benzodiazepines, neostigmine for neuromuscular blockers, and sugammadex ( for the neuromuscular blockers rocuronium or vecuronium.

There are some meds that you’ll only see used for specific procedures or surgeries. A good example of a specialized med is cardioplegia, or cardioplegic, solution for cardiac bypass surgeries. These solutions contain electrolytes such as potassium chloride to arrest the heart muscle and keep it still while surgery is performed. There are different mixtures that can be used, which may depend in part on the surgeon’s preference and the bypass machine that’s being used. Double-check your pharmacy’s policies and procedures if you dispense or prepare cardioplegia solutions. You’ll likely need to affix auxiliary labels such as “not for IV infusion” to the bags.

Sometimes patients will receive injectable dyes during procedures or scans to help clinicians visualize different types of tissues such as lymph nodes, or to see how well certain organs are working. These dyes include indigo carmine, indocyanine green (IC-Green, etc), isosulfan blue (Lymphazurin, etc), and methylene blue (ProvayBlue, etc). Keep in mind that you may also see methylene blue used for treatment of toxicities such as from chemicals or other meds (e.g., ifosfamide), or to treat a blood disorder called “methemoglobinemia.” Some things to remember about dyes include the fact that they are costly (usually $200 or more per ampule or vial), and that they may not be interchangeable. (The question of interchangeability with these meds may be especially important since there have been numerous shortages of dyes recently.) For example, substituting methylene blue for indigo carmine could lead to dangerous drug interactions, since methylene blue is a monoamine oxidase inhibitor (MAOI) that could cause serotonin syndrome in a patient who’s also taking serotonergic meds such as certain antidepressants. And dispensing methylene blue instead of trypan blue (VisionBlue) for ophthalmic use has led to vision loss.

Who administers meds during surgeries?

Often, the individual who preps meds in an operating room might also administer the meds. For example, an anesthesiologist might select, prepare, label, and administer a dose of an opioid such as fentanyl. This is part of the reason that there is a high risk of errors. Checks such as by a pharmacist or a computer system are often skipped.

Another problem is that there are multiple people in an operating room, including anesthesiologists, surgeons, nurses, etc, which could also increase the risk of errors. For example, if a med is prepped by one person, but not properly labeled, another person could make an assumption about what the med is, when it was prepped, etc, leading to an error. It’s easy to see why there’s been a big push from safety experts to label all meds in operating rooms.

What med errors are common in operating rooms?

It’s important to emphasize that many of the meds used in operating rooms are high-alert: injectable opioids, vasopressors (e.g., phenylephrine, norepinephrine, etc), paralyzing agents (e.g., cisatracurium, etc), and so on. This means that any errors are especially dangerous to patients.

Product selection mix-ups, such as selecting the wrong med vial out of a bin or tray, are a big problem in operating rooms. The risk of these errors can be increased when meds come in similar packaging, or with meds that have similar looking or sounding names. It is not uncommon for operating room staff to be on “autopilot” in some ways, and reach for a med in a spot where they’re used to finding it, or assume the contents of a syringe or vial based solely on its appearance. This is easy to imagine in a high-pressure, fast-paced practice setting. The lack of certain technology, such as bar code scanning, can exacerbate the issue of product selection mix-ups.

Giving meds by the wrong route is another problem, such as when a med is given by epidural injection rather than by IV injection by accident. Here’s an example. The med tranexamic acid, which is used to stop bleeding, has been mixed up with bupivacaine and accidentally injected epidurally, due to similar looking vials. The results of these dangerous errors have included fatalities, and they can be considered under the umbrella of product selection mix-ups.

Also, choosing a wrong prepared syringe is a problem. For example, an anesthesiologist might have multiple meds drawn in syringes, and choose the wrong one to administer. This error goes hand in hand with another common source of errors in operating rooms: a lack of proper labeling of meds. Every container should be labeled with the med it holds, med concentration, and date and time of prep. Unfortunately, this is often not the case.

As you can imagine, delaying treatment in surgery patients can be dangerous. These patients are often in critical situations, where minutes really do count. You might expect this for patients such as those who come in with serious traumatic injuries. But keep in mind that a planned, routine procedure can go south too, where the patient needs certain meds right away. Lack of communication in an operating room, or lack of communication in the pharmacy, can put patients in perilous situations when meds are needed urgently.

How can I help prevent common med errors in operating rooms?

One of the big strategies for preventing product selection errors in ORs is to standardize. This means standardizing stock formats and also standardizing meds.

With regard to standardizing operating room stock, try to keep the same formation or layout in bins, carts, trays, and automated dispensing cabinets whenever possible. Also try to streamline, by keeping an eye out for meds or med concentrations that are used infrequently. It may be possible to remove these from operating room stock altogether, to reduce clutter.

When you’re stocking meds for operating rooms, stay alert for look-alike/sound-alike meds. Bring these to the attention of your admin, so they can use strategies to help avoid mix-ups. An example of this might be when a new generic of a med in a vial comes in your stock, and you notice it has the same size and cap/label color as another med that’s kept in the operating room. If another generic for one of the meds, with a different appearance, isn’t available, you might need to use shelf tags and separate the meds to help avoid mix-ups.

One of the most serious product selection errors that can happen involves paralyzing agents, or neuromuscular blockers. These paralyze a patient completely, so the patient cannot move, speak, or breathe. Operating rooms are the main place where these meds are used. To help prevent errors with paralyzing agents, place them in lock-lidded pockets when they’re stocked in automated dispensing cabinets or in sealed boxes with breakaway locks when they aren’t in automated dispensing cabinets. Also separate your stock of paralyzing agents from other medications in the pharmacy. Be sure to label these meds with auxiliary labels stating “Warning: paralyzing agent-causes respiratory arrest.” These can help differentiate them from other meds, and stop errors in their tracks.

Encourage OR staff to read vial labels rather than depending on familiar packaging by stocking vials and other meds so their labels are visible. You may find special organizers that can hold vials horizontally useful for this purpose.

You may find “stashes” of meds in operating rooms, where doctors or nurses keep their own stock of meds. These stashes can be risky since the meds may not be kept in proper conditions (e.g., refrigerated) or they may be mistakenly administered after their expiration date. Let your pharmacist or admin know about stashes, so they can find out why operating room staff are resorting to this potentially dangerous workaround, and work with them to find mutually acceptable solutions.

Another way to prevent product mix-ups is to use clear communication with operating room staff and also with your pharmacy colleagues. Jargon such as saying “neo” instead of phenylephrine (Neo-Synephrine), “nitro” instead of nitroglycerin or nitroprusside, or “levo” instead of norepinephrine (Levophed) can lead to confusion, at least, and errors, at worst.

With regard to standardizing meds, try to stick with preparing concentrations of infusions and other preps that your pharmacy considers their standard. If non-standard concentrations are requested, check with your pharmacist before prepping or dispensing them. They may be able to work with operating room staff to switch to a standard concentration. An example of a standard concentration for operating room use might be a phenylephrine 60 mg/250 mL infusion. If a phenylephrine 30 mg/250 mL infusion is requested, a simple phone call from the pharmacist may be all that’s needed to make a switch to the standard.

If you find that you have multiple concentrations of infusions and other preps, check with your pharmacist to find out how you can narrow them down. It may be possible to choose just one if you have three or four, if clinicians are able to come to an agreement.

To help prevent errors due to labeling issues, pharmacies are prepping more operating room meds in the pharmacy, to ensure that they’ll have proper labeling (e.g., drug name, concentration, beyond-use date). If this is the case in your pharmacy, help ensure that these meds are available quickly for operating room staff, to prevent the temptation to use workarounds. You may want to batch certain preps if you know multiple doses will requested each day. Monitor the number of preps used each day, so you can continually adjust the number you batch to avoid waste or running short.

If meds that you prep in the pharmacy for operating rooms have labels with bar codes that must be scanned before the med is administered, help operating room staff trouble shoot if there are problems. Also, help communicate problems to your admin or pharmacist, if necessary. A system that’s consistently problematic could tempt operating room staff to use workarounds. And if you’re responsible for stocking labels in the operating rooms for staff to affix to meds, such as from printers that generate labels with bar codes, ensure the labels don’t run out.

To prevent treatment delays for surgery patients, consider any orders for patients in surgery to be STAT. Even small delays can be a big deal since meds may be needed to stabilize vital signs, stop bleeding, treat pain, etc. Make frequently used meds readily available if possible, such as by stocking them in automated dispensing cabinets (ADCs). For example, operating room staff can have quicker access to antibiotics if they’re kept in ADCs in preoperative “holding rooms” and in operating rooms. Batching frequently used meds, as discussed in a previous section, is another way to help prevent treatment delays. You may be able to stock these batched meds in ADCs in operating rooms, or you may need to dispense them from the pharmacy. Either way, you cut down on prep time. Work with your pharmacist and admin to identify opportunities to improve med accessibility for your hospital’s operating rooms.

Project Leader in preparation of this technician tutorial (321181): Stacy A. Hester, R.Ph., BCPS, Associate Editor; Last modified May 2017

Cite this document as follows: Technician Tutorial, Dispensing Meds for Surgeries. Pharmacist’s Letter/Pharmacy Technician’s Letter. November 2016.