Dispensing Meds for Surgeries

Full update August 2020

Many inpatients, and some outpatients, will need to undergo surgical procedures. These can sometimes be done at bedside, but often they require patients to go into an operating room (OR). Surgical procedures can be relatively short and simple, such as IV line placement or wound cleaning. Or, they can be major, such as operations involving the brain or heart. Patients often receive many meds in a short period of time during surgeries, and they’re at an especially high risk of experiencing med errors. In fact, it’s been suggested that med errors occur in about 50% of surgeries. The fast-paced perioperative environment and lack of some usual checks and balances may contribute to the risk. Longer surgeries and surgeries where more meds are given seem to have a higher risk of errors. The good news is that most med errors in surgery patients are preventable. And groups such as Joint Commission are pushing to improve patient safety in operating rooms. This technician tutorial will cover basic information about perioperative med use, along with useful tips for reducing error risk.

What are the different kinds of meds used during surgeries?

A wide variety of meds are used during surgeries, partly because there are so many different kinds of surgeries. Here are some of the most common.

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

Patients may need additional meds to provide pain control (i.e., analgesia), such as injectable opioids (e.g., fentanyl, hydromorphone, morphine). Usually analgesics are given by IV push or infusion, but they may also be injected into the spinal column in some cases. This is one reason you’ll see preservative-free versions used in operating rooms. Versions with preservatives can’t be given by the epidural or intrathecal 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, 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 (e.g., blood pressure, heart rate). 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 Gelfoam and Tisseel. They typically contain substances found naturally 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 will need antibiotics perioperatively to prevent surgical site infections. Surgical site infections occur when bacteria are transferred from one part of the body to another during a procedure, such as from the skin into an incision in the abdomen. Cefazolin is a common choice, since it’s effective for skin organisms. But you’ll also see other antibiotics (e.g., clindamycin, vancomycin) used depending on the procedure. There are two important things to note about perioperative antibiotics. One is that doses of cefazolin may be higher than you’re 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. Giving these extra doses helps keep blood levels of the antibiotic up, and your hospital likely has guidance on this.

Patients may require “reversal agents” to reverse the effects of anesthetics and analgesics, so the patient regains consciousness after a surgery. These include naloxone for opioids, flumazenil for benzodiazepines, neostigmine for neuromuscular blockers, and sugammadex (Bridion) for the neuromuscular blockers rocuronium or vecuronium.

There are some meds that you’ll only see used for specific surgeries. A good example is cardioplegia, or cardioplegic, solution for cardiac bypass. These solutions contain electrolytes such as potassium chloride to keep the heart muscle still during surgery. There are different mixtures that can be used, which may depend 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 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 and that they may not be interchangeable. (The question of interchangeability with these meds may be especially important if there are shortages of a particular dye.) 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 (e.g., certain antidepressants, linezolid). And dispensing methylene blue instead of trypan blue (VisionBlue) for ophthalmic use has led to vision loss.

Who administers meds during surgeries?

Often, the clinician who preps meds in an operating room also gives the meds. For example, an anesthesiologist might select, draw up, label, and administer a dose of fentanyl. This may be part of the reason there’s such a high risk of errors. It differs from the typical process where a prescriber orders a med, a pharmacist dispenses the med, and a nurse administers the med and monitors its effects.

Another factor that could increase error risk is the multiple people required in the relatively small space of an operating room, including anesthesiologists, surgeons, nurses, etc. For instance, 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, and administer the med, leading to a potentially serious 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?

Many of the meds used in operating rooms are considered high-alert: anticoagulants (e.g., heparin), injectable opioids, vasopressors (e.g., phenylephrine, norepinephrine), paralyzing agents (e.g., cisatracurium), and so on. This means any errors are likely to be especially dangerous to patients. Plus, operating rooms have been hit hard by drug shortages, adding in an extra complicating factor.

Product selection mix-ups, such as grabbing the wrong med vial from a bin or tray, are a big problem in operating rooms. The risk can be increased when multiple meds come in similar packaging, or with meds that have similar looking or sounding names. It’s not uncommon for operating room staff to be on “autopilot” in some ways, and reach for a med where they’re used to finding it, or assume the contents of a syringe or vial based on its appearance (e.g., package size, label color). 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 accidentally given by epidural injection rather than by IV injection, or vice versa. Here’s an example. Tranexamic acid has been mixed up with bupivacaine and accidentally injected epidurally, due to similar looking vials. Another example is when topical thrombin is accidentally injected, leading to unwanted clotting of the blood. The results of these dangerous errors have included fatalities.

Also, choosing the wrong prepared syringe is a problem. For example, an anesthesiologist might have multiple meds drawn into syringes, and reach for 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 at least the med it holds, med concentration, and date and time of prep.

As you can imagine, delaying treatment in surgery patients can be dangerous. There are often critical situations where minutes really do count. You might expect this for certain patients, such as those who come in with serious traumatic injuries. But a planned, routine procedure can go south too, where the patient needs certain meds right away. Lack of communication when meds are needed urgently can lead to delays that put patients in peril.

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

One of the big strategies for preventing product selection errors in operating rooms is to standardize. This means standardizing stock formats and also standardizing meds that are stocked and used.

Keep the same format or layout in bins, carts, trays, and automated dispensing cabinets whenever possible. Also 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.

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, work with your pharmacy team 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.

When you’re stocking meds for operating rooms, stay alert for look-alike/sound-alike meds. Bring these to the attention of your pharmacist, supervisor, or med safety officer, so they can help implement error-prevention strategies. An example of this is when your pharmacy orders a new generic version of a med, and you notice the vial is the same size and has the same cap color as another med that’s kept in the same area. If an alternate version with a different appearance isn’t available, you might need to use shelf tags and separate the meds to 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, separate them from other meds, such as by placing them in lock-lidded pockets in automated dispensing cabinets. Be sure to label these meds with auxiliary labels stating “Warning: paralyzing agent-causes respiratory arrest.” These measures can help differentiate paralyzing agents from other meds with similar packaging and stop potentially deadly errors in their tracks.

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

Another way to avoid product mix-ups is to use clear communication with operating room staff and 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 serious errors, at worst.

To prevent errors due to labeling issues, pharmacies are prepping more perioperative meds in the pharmacy, so they’ll have proper labeling (e.g., med name, concentration, beyond-use date). If this is the case, ensure 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 be requested each day. Monitor the number of preps used, to adjust the number you batch to avoid waste or running short.

If meds have labels with bar codes that must be scanned before the med is administered, help operating room staff troubleshoot if there are problems. Also, communicate problems to your pharmacist, supervisor, or med safety officer if necessary. A system that’s consistently problematic could mean the operating room staff will resort to 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 in perioperative areas. 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 automated dispensing cabinets, or you may need to dispense them from the pharmacy. Either way, you cut down on prep time.

You may find “stashes” of meds in operating rooms, where clinicians keep their own stock of meds that they can access quickly. But these stashes can be risky since the meds may not be stored under proper conditions (e.g., refrigerated) or they may be mistakenly administered after their expiration date. Let your pharmacist, supervisor, or med safety officer know about stashes, so they can find out why operating room staff feel the need to keep them, and partner with these individuals to find mutually acceptable solutions.

What are other issues that can come up in perioperative environments?

Keep in mind that you’ll be required to wear appropriate garb when you go into certain perioperative areas if you’re restocking automated dispensing cabinets, refilling or switching out med trays, etc. If you’re unsure, check with your pharmacist or operating room staff about what you’ll need to wear, where to find garb, etc. Typically, you can expect to need a bouffant hair covering, a mask, hospital-issued scrubs, and shoe coverings.

Since there is high use of controlled substances in the perioperative setting, you will want to be up to speed on any policies and procedures related to preventing diversion of these meds. For example, you may need to reconcile, or match up, records of medication administration with records of meds removed from automated dispensing cabinets. Or, you may need to assist in wasting leftover or unused controlled substances from a surgical case.

Some equipment, including anesthesia carts, kits, or trays may require periodic decontamination, and you may play a role in facilitating this.

Project Leader in preparation of this technician tutorial (360881): Stacy A. Hester, R.Ph., BCPS, Associate Editor

Cite this document as follows: Technician Tutorial, Dispensing Meds for Surgeries. Pharmacist’s Letter/Pharmacy Technician’s Letter. August 2020.

─Please continue for a “Cheat Sheet” about Dispensing Meds for Surgeries─

“Cheat Sheet” for Dispensing Meds for Surgeries

There’s a high risk of med errors during surgery. Being familiar with meds used, common errors, and strategies to prevent errors is important if you work in a pharmacy that services operating rooms.

What are the different kinds of meds used during surgeries?

Many of the meds used during surgeries are high-alert, and you’ll almost certainly see these meds used in operating rooms.

  • Anesthetics, local (e.g., bupivacaine, ropivacaine) or general, either inhaled (e.g., desflurane, isoflurane) or injectable (e.g., etomidate, propofol)
  • Pain meds, such as opioids (e.g., fentanyl, hydromorphone)
  • Neuromuscular blockers (e.g., cisatracurium, succinylcholine)
  • Vasoactive meds (e.g., epinephrine, phenylephrine)
  • Hemostats, either injectable (e.g., tranexamic acid) or topical (e.g., fibrin, thrombin)
  • Antibiotics (e.g., cefazolin, vancomycin)
  • Reversal agents (e.g., naloxone for opioids, flumazenil for benzodiazepines)

Who administers meds during surgeries?

Often, the person who selects and preps a med will administer it, such as the anesthesiologist. This may increase risk for errors, since checks and balances that apply on other patient care units may not be in place.

What med errors are common in operating rooms?

Some errors that are common in operating rooms include the following:

  • Product selection errors, such as choosing the wrong vial from a med tray. This may be compounded by drug shortages that require using alternate products.
  • Giving meds by the wrong route, such as by injecting a med meant for topical administration.
  • Choosing the wrong prepared syringe, such as when multiple meds have been drawn into syringes and the person administering the med selects the wrong one. This may be compounded by inadequate labeling.
  • Delayed treatment, such as when there are communication breakdowns about a med needed right away.

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

  • Help standardize the meds that are dispensed and the way meds are stored.
  • Keep an eye out for meds that aren’t being used and see about eliminating them from stock, or limiting the quantity that’s stocked.
  • Help clean up “stashes” of meds, and address issues that cause clinicians to keep these meds on hand.
  • Stay alert for look-alike/sound-alike meds and use strategies, such as separating them, to avoid mix-ups.
  • Take extra precautions with high-alert meds, such as by separating neuromuscular blockers from other meds and applying warning labels to their containers and storage bins.
  • Position vials horizontally so that labels are visible, not just the caps.
  • Prep meds in the pharmacy to dispense to operating rooms, and ensure they’re properly labeled.
  • Be ready to address any bar-code scanning issues in operating rooms, to prevent clinicians from using workarounds and bypassing this safety check.

What are other issues that can come up in operating room environments?

  • Follow requirements for garbing (e.g., hair cover, shoe covers, mask) in certain areas.
  • Prevent diversion of controlled substances. Match up records of removal from automated dispensing cabinets and administration. Follow hospital policies for wasting unused drug.
  • Follow hospital policies for decontamination of carts, kits, or trays.

[August 2020; 360881]