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Another group of anesthesia professionals in Germany devised a comple-

Medication shortage can have a substantial impact on patient care and is responsible for creating an environment conducive to an increase in MEs. Anesthesiologists, in particular, were acutely affected by the drug shortage in the past two decades. In a recent survey on drug shortages in the United States from August through October 2017, most respondents conrmed that drug shortages during the 6months prior to the survey were a daily struggle. Shortages were reported across all treatment cate­gories, but more than two-thirds of respondents reported shortages that impacted anesthesia care (85%) and pain management (81%). The shortage of medications (e.g., ephedrine) may be due to the shortages of raw material [15]. The current shortage in the United States of some formulations of fentanyl, vecuronium, mid­azolam, etomidate, dexmedetomidine, and rocuronium has been reported to be the result of manufacturing-related issues [16]. The decrease in medication supply due to voluntary recalls is another important factor that can initiate an abrupt decrease in medication supply. Medication shortages have led to unsafe practices that have increased the risk of an error, thus impairing patient safety. Medication substitutes with higher concentration or potency than the ones routinely used can lead to over­dosing. For example, fentanyl overdosing can and has resulted in respiratory arrest because the shortage of 2-mL (50μg/mL) formulation of the drug and the purchase of the larger 5-mL ampoule size (total dose 250μg) created confusion for the health- care providers. Similarly, respiratory arrests requiring subsequent intensive care unit admission have occurred because sufentanil was used in substitution for fen­tanyl during a fentanyl shortage. Other similar errors can occur when healthcare providers use the higher concentration single-use vials for multiple patients. For example, an incident was reported recently where 50-mL vials of propofol were used for multiple endoscopy patients, resulting in the transmission of hepatitis C to some patients, and thousands of patients were exposed to human immunodeciency virus, hepatitis B, and hepatitis C [17]. Because of the pivotal role pharmacists play in dealing with medication shortages, the American Society of Health-System Pharmacists (ASHP) has developed a guideline to help institutions deal more effec­tively with medication shortages (Fig.4.2). This guideline involves three phases: identication and assessment, preparation, and contingency. During shortages, pharmacists should play a key role in a multidisciplinary approach for the prepara­tion, standardization, communication, and monitoring of medications to ensure patients’ safety.

Standardizing the concentration of drugs, infusion concentrations, and dosing units for IV continuous medications throughout the institution, including periopera­tive areas, is crucial to avoid confusion and ensure maximum safety [32]. This will standardize the preparation of drugs between pharmacy, nursing, and the anesthesia providers and minimize calculation and preparation errors. In 2016, the FDA awarded ASHP a 3-year contract to develop and implement national standardized concentrations for intravenous (IV) and oral liquid medications. “Standardize 4 Safety” was the rst inter-professional effort to standardize medication concentra­tions in the United States [31].

Example of those strategies include storing uncommonly used drugs (e.g., insu­lin or protamine) in a separate color-coded bin rather than the standard workspace and removing at the end of the case [31]. A team of anesthesiologists and designers at the University of Washington created the anesthesia medication template (AMT) to organize the anesthesia workspace to reduce perioperative medication errors by anesthesia providers [33]. The layout primarily consists of a series of three­dimensional cells devoted to specic medications or medication classes (Fig.4.6). In simulated emergencies, AMT signicantly decreased the risk of MEs (odds ratio

Computerized physician order entry (CPOE) systems with clinical decision support (CDS) have been shown to improve quality of care and reduce medical errors, but mistakes can still occur. For example, infusion pumps should be used to administer IV medications and uids. These devices accept a wide range of programming parameters per rate (from 1L per hour to one drop per hour) and volume (range from

Technology-assisted drug identication and conrmation like bar coding can improve medication safety in healthcare facilities. Bar coding on purchased or com­pounded syringes, ampoules, or vials would prevent syringe or ampoule swap. Many US hospitals started the use of the “Safe Label System” which uses a bar code-assisted method of medication identication and labeling with audio and visual conrmation of the medication name, and printing of a label. This modality has been suggested to improve efciency as well as compliance to 100% compared with standard methods [35].

The preparation/compounding of prelled or premixed solutions with appropri­ate labeling eliminates miscalculation errors made by the healthcare providers in the perioperative setting. In addition, this process would decrease the waste of drugs by assigning an extended beyond-use date for drugs when prepared in an IV admixture unit meeting the USP<797> criteria [40]. There are inherent risks in sterile compounding, and quality assurance systems should be in place to avoid contamination of the nal product (e.g., hand hygiene, aseptic technique, and microbial monitoring). Compounding of medications is costly, time consuming, and requires resources. In the United States, prelled syringes are available by dif­ferent manufacturers or by third-party medication distribution centers that repack­age bulk drugs under the FDA section 503B of the Federal Food, Drug and Cosmetic Act exempted from the New Drug Approval (NDA) process. Pharmacists have a major role in validating the quality of the product and the labeling criteria to ensure safety.

Recent use of the radiofrequency identication (RFID) technology has been shown to eliminate preparation errors of the kits and increases productivity by reducing time spent on restocking and verifying kits. RFID-tagged items can be scanned all at once by placing the items in an RFID-based scanning device to com­pare the contents of the kit with the contents specied by the database of the institu­tion [41].

Clinical pharmacists can lead the efforts to develop guidelines and incorporate them in the health information system, when available, for high-alert medications such as neuromuscular blocking agents, synthetic opioids, and propofol. They can be in charge of monitoring compliance and clinical outcomes.

Clinical pharmacists can play an important role in providing timely and accurate drug information to healthcare professionals as related to shortages,