Table 3.

Recommendations to reduce medication errors[59]

Patient information	• Consistent documentation and complete operative medication history
	• Add prompts to pre admission card
Drug information	• Provide enhanced pharmacist support
Communication of drug orders and information	• Eliminate use of dangerous abbreviations and dose expressions
	• Incorporate computerised physician order entry into strategic planning
Drug labelling, packaging and nomenclature	• Enhance communication mechanism
	• Standardised anaesthetic cart trays and consider usage pattern
	• Labelling of all medication and solutions
	• Standardise labelling procedures
Drug standardisation, storage and distribution	• Evaluate the need and then clearly identify and segregate hazardous products
	• Increased provision of premixed solutions
	• Segregate and label, storage areas for neuromuscular blockers
	• Acquisition of prefilled automated dispensing cabinet
	• Incorporate bar coding system
Environment and workflow	• Minimize advance preparation of drug syringe
	• Return or remove unused medication from work cart
Staff competency and education	• Investigate, evaluate and educate staff about the dangers associated with workaround practices
Patient education	• Provide enhanced education material for preoperative patients
	• Consider pharmacy involvement in same day assessment
Quality processes and risk management	• Encourage reporting (including nearmisses) by all practitioners
	• Consider monitoring use of all trigger drugs
	• Consistently employ independent double checks for hospital selected ‘“high alert”’ drugs