Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 2

Abstract

For decades, the dental profession has provided the full spectrum of anesthesia services ranging from local anesthesia to general anesthesia in the office-based ambulatory environment to alleviate pain and anxiety. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article illuminated the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medical anesthesia has implemented to manage such problems that may have utility in dentistry, and introduce a novel method for addressing these issues within dentistry known as the Dental Anesthesia Medication Safety Paradigm (DAMSP).

With the recent increase in national attention directed at patient safety involving sedation and anesthesia for dentistry within the office-based environment, organizations inside and outside of dentistry are attempting to collect and evaluate data to improve outcomes and reduce or eliminate untoward events. However, given the general isolated nature of most dental practices, this has proved challenging. Unlike the hospital setting, which can provide abundant opportunity for licensed health care providers to practice in an environment prime for collaboration with systematic or redundant decision-making support and oversight, dentists often practice in a solo fashion, working essentially independently in an environment mostly devoid of the aforementioned benefits. Even in a group practice setting, dentists tend to operate in working environments where they are the only licensed health care professional making individual patient care decisions. This inherent lack of systemic or institutional support means the dentist is often the sole decision maker with virtually no oversight that might otherwise help reveal issues, be them realized or potential, regarding patient safety. Furthermore, state dental boards and insurance companies are quite reluctant to release information, even de-identified, that might help shed light on patient safety issues primarily due to concerns over litigation. The interplay of these various aspects has made it quite difficult to collect accurate and verified data from the dental profession.

Despite the difficulty in truly assessing patient safety concerns in dentistry, 2 areas of interest, directly related, are medication errors and adverse drug events. Reducing the incidence of these issues is particularly critical for those dentists practicing sedation and general anesthesia due to the implicit risks associated with anesthetic agents, although the same goal could, and likely should, be applied to all of dentistry. A thorough discussion of these 2 issues can be found in Part 1 of this series. However, to summarize, a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.¹ An adverse drug event is an injury that may be predictable or unpredictable resulting from medical intervention related to a drug.² Although these issues may be related, they are not necessarily codependent. An adverse drug event may or may not be due to a medication error, and a medication error may or may not result in an adverse drug event.

As detailed in Part 1, medication errors and adverse drug events have been studied extensively for over 30 years in medicine and anesthesia with numerous safety initiatives having been postulated and implemented in efforts to reduce their incidence. Unfortunately, aside from case reports, there is a paucity of scientific literature related to incident rates in dentistry. Much of what is known about these phenomena has been extrapolated from the medical literature.

Continuing the discussion, Part 2 of this series will specifically address medication errors and adverse drug events in dentistry by reviewing several ways medicine and anesthesia have approached these issues and offering suggestions for incorporating many of those same ideas into dentistry where practical, introduced here as the Dental Anesthesia Medication Safety Paradigm (DAMSP).

ANESTHESIOLOGY AND PATIENT SAFETY

Anesthesiology has a long, successful record as the pioneer in patient safety dating back to the formation of the Anesthesia Closed Claim Project, established by the American Society of Anesthesiologists and the University of Washington at Seattle in 1984, and the Anesthesia Patient Safety Foundation in 1985. Other notable accomplishments include improvements to anesthesia machines, technological advancements in patient monitoring and airway management, and focused efforts on reducing airway and ventilation-related complications. Anesthesia has also employed several safety strategies co-opted directly from the field of aviation, such as the use of checklists and simulation training. As a result of these measures, anesthesiology has successfully established a culture dedicated to patient safety.

However, additional room for improvement exists regarding medication errors and adverse drug events as detailed in Part 1. Perioperative medication administration is a complex process often involving multiple steps, with the potential for errors existing at all stages (Table 1). Unfortunately, issues related to intravenous (IV) medication use are often more difficult to manage given that IV medications are generally less tolerant of mistakes than inhalational agents and the workflow challenges providers face. The anesthesia approach to IV agents remains rather primitive, fragmented, and cavalier.³ Medication errors in anesthesia were first reported in 1954,⁴ and from the earliest to the most recent reports, the prevalence of medication errors and adverse drug events during anesthesia surprisingly has not markedly improved.

Table 1. .

Common Types of Perioperative Medication Errors*

Medication Errors by Step
Requesting	Incorrect drug requested Miscommunication of drug request
Obtaining	Incorrect drug selected/received Dispensing error Expired/deteriorated drug error
Preparing	Labeling error Incorrect dosage prepared Incorrect drug prepared
Administering	Improper dose: overdose/under dose Incorrect timing Incorrect route Inadvertent bolus
Recording	Incorrect time or dosage recorded Omission error
Monitoring effect	Idiosyncratic reaction/allergic reaction Improper depth of sedation/anesthesia
Discarding	Inappropriate disposal

^*Sarasin DS, Brady JW, et al. Medication safety: reducing anesthesia medication errors and adverse drug events in dentistry part 1. Anesth Prog. 2019;66:162–172.

Fortunately, research efforts to recognize the incidence, causes, and associated human factors are trending upwards.⁵ Abrishami et al⁶ found that the number of studies reporting medication errors has increased exponentially over the past 20 years. Interestingly, the types of medication errors being commonly reported has not changed.^7–10 This may be, in large part, due to inaccurate identification and reporting of these mishaps as previously discussed in Part 1, although other factors are likely involved including institutional support, method of implementation, education, and compliance.

MEDICAL ANESTHESIA STRATEGIES

The ASA as well as other national and international organizations have made significant efforts to explore new ways to prevent errors from reaching or harming patients. Various strategies to reduce medication errors in anesthesia have been proposed since John Snow first advocated for the use of a specific chloroform mask to reduce the concentration errors with inhalation anesthesia in 1848.¹¹ In 2004, Jensen et al¹² developed 1 general and 5 specific strong evidence-based recommendations for reducing drug administration errors during anesthesia from a systematic review of the literature (Table 2).

Table 2.

Medication Safety Strategies

Theme	Recommended Strategy*
Patient information	• Complete medication reconciliation • Medications charted in standard format • Single location for recording medications given during surgery (preoperative to PACU) • Time out - patient information, weight, allergy, medication given (eg, premed) • Automated alerts within anesthesia info system (dose, allergy, drug interactions) • Established weight-based dose limits (eg, infusion pump prompts)
Drug info	• Cognitive aids, checklists, emergency protocols, infusion rate charts • Specialized protocol carts (eg, MH, cardiac arrest)
Cart inventory	• Standardize, label, organize drug trays in anesthesia carts • Eliminate unusual drugs from usual locations (unique location, remove at end of case) • Single-use vials preferable, if multidose vial required, discard at the end of the case • Management of dangerous drugs - One standard concentration on cart; No concentrated drugs (pharmacy provides diluted or high-risk drugs, no large volume epinephrine) • Separate regional cart for regional drugs (regional agents separated from IV agents); Preservative free local anesthetics; SQ or topical anesthetics labeled)
Administration	• Every medication labeled with name/date/concentration; Barcoding system use optimal, otherwise preprinted/color coded per ISO standards; Avoid abbreviation and “0” issues; Unlabeled syringes or vials immediately discarded • Minimize provider-prepared syringes, pharmacy prefilled when possible; Ideally pharmacy prepares compounded and diluted drugs, otherwise provider prepares dilution of high risk meds using 2-person check if available, otherwise careful double check; Verify high-risk medications and weight-based doses with 2 people • Asepsis; Cap syringes; Sterile techniques for spinal/epidural placement, injections • Read/verify every ampule, vial, or syringe label before administration; Barcode system use with audible/visual cues optimal, otherwise 2-person verification if available • All infusions with smart pumps standardized across units with guardrail libraries and alerts • Clearly identified appropriate route of administration (route-specific sets, color-coding routes); Label on every infusion line/port; No port on epidural/intrathecal lines • Sterile field drugs (1 drug passed to field at a time); 2-person check (drug name, date, concentration on label); Unlabeled drugs discarded • Clean sweep (discard all syringes, containers/vials at end of case unless connected to patient)
Culture	• Nonpunitive QA system for incident reporting, analysis, and intervention • Written policies for medication safety; Educate new staff on policies • Establish a culture of respect and collaboration endorsing patient safety and compliance • Adequate supervision, teaching, and in-service training
Pharmacy	• Formulary designed to avoid purchase of “look-a-like” medications (if unable to avoid, do not store in proximity); Add special alert label to “look-a-like” medications • Pharmacy support for OR; Available 24/7 • Pharmacists participation in education and M&M • OR Pharmacists receive specialized education regarding OR • Pharmacy responsible for medication flow (ordering to discard) • Pharmacy stocks, tracks, and delivers drug trays • Pharmacy prepares infusions and all compounded or diluted high-risk drugs • Clean sweep policy for returned unused or unusual drugs • Change in drugs supplied (new labels or concentrations) requires alert to staff and possible alert labels on new drugs • Unique IV solutions stored separate from regular IV solutions

^*PACU indicates post anesthesia care unit; MH, malignant hyperthermia; SQ, subcutaneous; ISO, International Organization for Standards; QA, quality assurance; M&M, morbidity and mortality.

In the 16 years following that publication, numerous expert opinion-based consensus statements have been released. In January 2010, the Anesthesia Patient Safety Foundation hosted a consensus conference on medication safety in the operating room (OR) resulting in the development a new paradigm focusing on Standardization, Technology, Pharmacy/Prefilled/Premixed, and Culture.¹³ Due to the lack of randomized controlled studies, Wahr et al¹⁴ performed an extensive literature search published in 2016 that included the terms medication errors, medication safety, OR, and anesthesia to identify recommendations as supported primarily by experts in anesthesiology, OR pharmacy, and human factor engineering. A total of 74 articles were included as well as 6 guidelines or sets of initiatives regarding medication safety by national and international organizations. This yielded a total of 138 individual and 35 specific comprehensive strategies to prevent common and uncommon medication errors (Table 3). The authors of this study posit that these recommendations may serve as a tool for institutions to assess their vulnerabilities and develop/institute systematic solutions.

Table 3.

Evidence-Based Recommendations to Reduce Medication Errors

1. Overcome systemic challenges that may lead to increased medication error rates

2. Read the label before any drug is drawn up or administered

3. Ensure legibility and that label details that meet agreed upon standards

4. Always label syringes

5. Standardize and organize drug trays and workspaces

6. Drug labeling should be verified with an additional provider or through a barcode reader

Numerous studies have been published examining a variety of safety initiatives for improving perioperative medication safety both before and after the literature review by Wahr et al.¹⁴ A randomized, controlled trial by Merry et al¹⁵ compared the use of a multimodal system (SAFER SleepSystem™; Safer Sleep, LLC, Auckland, NZ) versus conventional methods on reducing drug or recording errors in anesthesia. They demonstrated that the new comprehensive organization, labeling, and administration system, which incorporated medication barcoding, prefilled syringes, audiovisual cues immediately preceding drug administration, and an automated anesthesia record, did not add to the workload of clinicians and reduced errors by 21%. The biggest reduction was in recording errors and, although the newer system had fewer drug administration errors than conventional methods, the difference was not statistically significant. The authors did note that the overall incidence of drug administration errors was higher than previously estimated suggesting that many errors go unnoticed by the anesthesiologist who makes them and that the incident reporting tends to underestimate the problem.

In 2017, Grigg et al¹⁶ prospectively assessed the impact of an anesthesia medication template (AMT) on medication errors by anesthesia providers during simulation and in the OR. Using individuals with expertise in visual, interaction and industrial design, cognitive psychology, and experience designing aircraft cockpits in collaboration with anesthesiologists, a 3-dimensional template was created as a formal way of standardizing, organizing, and identifying medication syringes in the anesthesia work station. When providers selected a prefilled syringe to administer a medication, they identified the correct one using several different factors including text, shape, size, color, and location. The AMT is a cognitive artifact that optimized all these factors to ensure providers selected the appropriate syringe with minimal cognitive processing. Wrong drug (syringe swap), dosing errors, and medication search time were examined, and use of the AMT reduced the mean monthly drug error rate reaching patients from 1.24 to 0.65 per 1000 anesthetics. The mean monthly error rate of syringe swaps, miscalculations, and timing errors decreased from 0.97 to 0.35 per 1000 anesthetics. The primary limitation of this study was that all errors were self-reported.

Use of prefilled labeled syringes is another safety strategy that can reduce the potential for medication errors and adverse drug events. A human-factors engineering study identified 8 system vulnerabilities with prefilled syringes, whereas self-filled syringes had 21.¹⁷ A failure modes and effects analysis of the anesthesia medication cycle revealed that the use of prefilled syringes, in addition to improving syringe labeling, standardizing medication organization in the anesthesia workspace, and incorporating 2-provider infusion checks, lowered the median medication error rate from 1.56 to 0.95 per 1000 anesthetics.¹⁸

Substantial potential clearly exists for reducing medication-related harm in the perioperative setting; however, there is not one simple solution. Widespread efforts are needed to look at the design of medication administration workflow and implement a variety of strategies to prevent medication errors and adverse drug events. To optimally manage these issues, 3 things must be realized:

1. all medication errors, including those that do not cause harm to the patient (ie, near misses), are important to report and to prevent;

2. the anesthesia provider who makes an error must identify that an error was made; and

3. the error is reported.

Intentional underreporting does not make the cause of problems to go away. Although most medication errors can be attributed to human error, the role of systemic flaws cannot be understated.

TRANSLATING MEDICAL STRATEGIES INTO DENTISTRY

As mentioned previously, the office-based dental environment is vastly different than the hospital setting, lacking the institutional support systems that provide oversight and helpful redundancy to combat medication errors and adverse drug events. The pharmacy staff in a hospital handle most, if not all, of the issues related to drug procurement while also serving as a valuable resource for clinicians by checking for drug interactions or handling drug dilutions for example. Dental practices must handle these tasks internally, which fall under the purview of the licensed anesthesia provider (ie, the dentist).

Additional challenges in the form of financial constraints become readily apparent when considering implementation of several of the various safety initiatives discussed above in dentistry. Prefilled syringes clearly demonstrated a reduction in medication errors; however, prefilled syringes are simply not available or cost effective for use in most dental practices. Barcode readers, automated drug dispensing cabinets, and automated anesthesia/electronic medical records are utilized in many hospital systems but are not practical in most dental practices due primarily to cost. Anesthesia providers in dentistry must balance the benefits gained from these safety initiatives against the potential financial and practical drawbacks.

DENTAL ANESTHESIA MEDICATION SAFETY PARADIGM (DAMSP)

The DAMSP was developed to address the unique medication safety considerations for anesthesia in dentistry. This paradigm attempts to reconcile several of the major strategies implemented by medical anesthesia with the uniqueness of the office-based dental environment. It focuses on 4 general guidelines that are integral to reducing anesthesia medication errors and adverse drug events in dentistry (Table 4). Although these concepts are likely applicable for all dental providers (eg, emergency medications), the remaining discussion will focus directly on those utilizing sedation and general anesthesia.

Table 4.

Dental Anesthesia Medication Safety Paradigm (DAMSP)

Dental Anesthesia Medication Safety Paradigm
Improve the Culture of Medication Safety
Know the Patient
Know the Drugs
Improve the Management of Anesthesia and Emergency Medications

Improve the Culture of Medication Safety

Improving medication safety starts with a heightened awareness that medication errors and adverse drug events can and do occur in dental offices. Every practice that utilizes sedation or general anesthesia should be aware of the potential dangers and have support systems, policies, and processes in place specifically designed to help combat these issues. Continuing education and routine training for all dentists and staff members focusing on medication safety is essential, particularly for those directly involved with patient care. The gravity of anesthesia-related adverse drug events should be reiterated frequently, and training should include the prevention, identification, and management of medication errors as appropriate. Practices must strive to create a positive work environment where all feel free to speak up if they see a potential problem. Clinical workspaces should be equipped with emergency management reference materials and visual aids that can be periodically reviewed and accessed immediately if needed. The algorithms detailed within the ADSA Ten Minutes Saves a Life! app (American Dental Society of Anesthesiology, Chicago, IL) are also available in a hardcopy format as a printed manual and can serve as an excellent resource for reviewing crisis events and practicing emergency responses (Image 1).

Image 1.

Emergency algorithms selection page within the ADSA Ten Minutes Saves a Life! mobile app.

Incorporating formalized regularly scheduled simulated emergencies involving staff members is an excellent way to build a culture of safety. Ideally, these mock drills should occur monthly, or quarterly at a minimum, and should include adverse drug events as a routinely occurring element. Continuing education and formal simulation courses are additional avenues for increasing training and emergency preparedness for providers and staff.

Mobile clinicians who provide anesthesia services in multiple locations should ensure that each location is properly equipped and staff trained to handle potential issues. Time should be spent training personnel as appropriate to understand the potential for medication errors and adverse drug events and recognize the necessary steps for prevention. The addition of a highly trained, licensed medical professional (eg, a registered nurse or paramedic) can be useful for any practice, especially mobile anesthesia providers, adding an extra layer of protection coupled with potentially life-saving experience during adverse drug events and other emergencies.

Utilizing the help of optimally trained support staff is critical for every sedation or anesthesia provider as there are real strengths to functioning as a well-organized team. However, it must be clearly understood that the responsibility of ensuring the safety of the patient rests fully with the licensed anesthesia provider and cannot be legally delegated to other nonlicensed providers or staff. Implementing appropriate safety strategies and optimizing the culture regarding medication safety provide essential support for clinicians to help ensure patient care is delivered in a safe and effective manner.

Know the Patient

A thorough knowledge of the patient is a universal requirement of all dental care. However, incorporating sedation or general anesthesia clearly elevates the preoperative assessment to a new level with added components such as a more comprehensive physical assessment and an airway examination. A thorough preanesthetic evaluation, replete with all its necessary components, must be completed prior to any anesthetic. Anesthesia providers working in hospitals often have easy access to patient information (ie, health history, patient medications, etc) and preoperative labs or tests if needed. Clinicians providing office-based anesthesia are held to the same standard of care but often lack access to the same network of information. However, a completed accurate preanesthetic evaluation is essential nonetheless.

A comprehensive understanding of each patient's unique anesthetic requirements is an integral part of preventing medication errors and adverse drug events. A list of all current medications, including recreational drugs and supplements, must be reviewed and potential drug interactions involving proposed anesthetic agents carefully assessed. If altering the patient's normal medication regimen is indicated, any adjustments should be provided to the patient in clear concise written instructions and fully documented by the anesthesia provider. Medication errors are commonly seen during transference of care (ie, from nursing home to the dental facility and back). As such, clear communication with the patient and their escort is critical. All team members involved in the patient's care should be aware of the anesthetic plan and any relevant medical issues to increase the likelihood of any adverse drug events or complications being identified early and managed accordingly.

Know the Drugs

Optimal outcomes require sedation and anesthesia providers possess a thorough understanding of each drug being utilized including a drug's mechanism of action, potential side effects, drug interactions, and proper dosing recommendations. Reviews of all drugs used in the office should be performed periodically and attention given to new drug study information and product recalls. Careful study and research should precede the introduction of any new drug and all staff members should be trained on the proper administration and potential side effects as warranted. Expiration dates for all drugs should be regularly monitored, ideally with a system that provides reminders for reordering. The ADSA Ten Minutes Saves a Life! mobile app has an added feature that allows users to input expiration dates for each drug and sends alerts when expiration dates are approaching (Image 2).

Image 2.

Drug expiration page within the ADSA Ten Minutes Saves a Life! mobile app.

Medication pharmacokinetic and pharmacodynamic variations between age groups must be appreciated to safely administer sedation and anesthesia. These differences can predispose certain patient groups to adverse drug events due to inappropriate dosing (eg, under or overdosing) if dosages and/or timing of administration is not adjusted. Regarding drug pharmacodynamics, during the extremes of age, neurotransmitters, hormones, and receptors can play different roles leading to unexpected responses to medications. In addition, medical comorbidities and their treatment regimens can affect both drug pharmacokinetics and pharmacodynamics often necessitating adjustments to administered drugs.

Improve Management of Anesthesia and Emergency Medications

Increasing medication safety requires appropriate management of anesthetic agents and emergency drugs. In dental facilities, medication management begins with the ordering of drugs and ends with the disposal of any unused agents, with multiple steps in between. Medication errors and adverse drug events can occur in any phase of this process, so each step requires careful attention (Table 1).

Purchasing sedative or anesthetic drugs in the office-based environment may involve the use of multiple drug vendors. Attention to detail is necessary when ordering medications to ensure the proper agents and intended concentrations are selected. This has become an increasingly critical issue due to medication shortages secondary to drug recalls. Frequently used agents may be replaced with different agents, brands, or drug concentrations. Using a different vendor can also lead to a provider inadvertently ordering a drug concentration different from what is routinely used. The anesthesia provider is implicitly responsible for all drugs. If the task of ordering drugs is delegated to a staff member, it is imperative all orders be reviewed by the anesthesia provider, especially if there are any noted alterations. The lack of a pharmacy to oversee and regulate drug procurement in the office-based environment necessitates that this process be carefully handled by the anesthesia provider.

Received medications must be carefully inspected, comparing the concentration of the received drug to the existing drug stock in the office to ensure the preparation is identical. Intentional changes in medication concentrations should be reviewed with all team members involved in anesthesia care. Visual reminders should be placed on any medications of differing concentrations as an added alert that different preparation may be necessary. Overheating or freezing of the medication prior to or during transport can occur. Inspection of the drug vials for damage and contamination is crucial. Drugs should be secured immediately upon delivery and inspection. Additionally, it is important to properly store medications in a sanitary, temperature-controlled environment as specified by the drug manufacturer. Controlled substances must be secured in adherence to state laws and Drug Enforcement Administration (DEA) storage requirements. Access to controlled substances should be limited to the anesthesia provider only; staff members should not be permitted access to the storage location.

Some anesthesia providers in dentistry are mobile and thus the drugs are stored, transported, and utilized in multiple locations. The mobile anesthesia provider has an added responsibility to ensure that each location meets the DEA and drug manufacturer's safety requirements. Mobile providers must also pay attention to the temperature and conditions of the vehicle during transport as extreme heat and cold can lead to inadvertent drug damage. Drugs should be kept at the manufacturer's recommended temperature during transport, and providers should inspect the vials for possible damage before use. Drugs should never be left in a vehicle or transport system unattended and must never be stored in a vehicle overnight.

A standardized method of drug storage should be utilized with all drug storage containers appropriately labeled indicating the correct location of each drug. Look alike/sound alike drugs must be intentionally separated, and the use of “tall man letters” on labels to highlight the differences in sound and appearance can provide additional help differentiating commonly confused drugs (Images 3 and 4). Additional markings made on the vial's flip top can help differentiate similar looking drugs. There is no standardization system for the vial lid colors. Different manufacturers may use alternative colors or change colors for the same drug or concentration, which may lead to confusion if providers and staff are inattentive. Special labels should be implemented to identify different concentrations if more than 1 concentration of the same drug is present in the dental facility. Providers that utilize more than 1 storage system should arrange each container in the same fashion to ensure consistency.

Images 3 and 4.

Ephedrine and epinephrine drug labels illustrating “tall man” lettering.

Proper drug preparation, including withdrawal of the drug from the vial and proper labeling of the syringe, is crucial. This should be performed utilizing strict sterile technique in accordance with the Centers for Disease Control and Prevention guidelines. In hospitals and many accredited surgery centers, infection control standards are regularly inspected by third-party infection control committees and accreditation agencies. This oversight is not routinely present in dental offices, requiring additional effort from the anesthesia provider to confirm that proper sterilization technique and infection control measures are in place and being utilized. Drug preparation should be performed in a clean, quiet environment to minimize distractions. The work area should be sterile and orderly, with the provider wearing gloves and a surgical mask to prevent bacterial transmission. Standard anesthetic medication vial dust covers do not offer barrier protection against the growth of pathogens.¹⁹ Rubber stoppers should be decontaminated with 70% alcohol or equivalent and allowed to dry prior to injection.²⁰ All staff members involved in anesthesia treatment should be trained in proper sterilization and infection control standards.

Single-patient medication vials are intended for 1 patient only and should be used whenever possible. It is necessary to check the medication and concentration on the vial to ensure the intended drug and concentration is drawn up. Two or more team members trained in medication safety should be present during drug preparation to reduce the risk of drug diversion; however, the anesthesia provider should be the only one to prepare or handle controlled substances. The preparation of drugs is not a task that can be delegated to other staff members.

Labels must be created and placed on the syringes immediately after they are filled. Information on the drug labels should include the drug name, concentration, time of preparation, and time of expiration. Using colored labels specific to each commonly used agent can help reduce wrong drug administration. Tall man lettering can also be used on syringe labels to highlight differences between similarly named drugs. Customized medication trays can be used to create an optimally organized anesthesia workspace.

The administration of a medication, proper documentation, and attentive monitoring of the effects should occur almost simultaneously. Each team member involved in anesthesia care must remain focused on the patient. The use of closed-loop communication among team members reduces communication problems and can improve documentation and monitoring. Reduction of outside distractions and interruptions during anesthesia, especially during administration of medication, is advised. Anesthesia providers should aim to create a positive work environment where each team member is comfortable speaking up as soon as they notice an error or potential adverse effect. “See something, say something” should be an accepted element of office culture.

Administration of intravenous medications should be performed using sterile techniques. Providers should check that the IV line is free flowing prior to drug administration and avoid leaving needles uncapped. Drugs should ideally be administered at the most proximal site and appropriate guidelines regarding the rate of drug delivery should always be followed. Unused medications must be properly discarded immediately after anesthesia has ended and the patient is recovering prior to discharge. This prevents inadvertent use of a medication on another patient and reduces the risk of drug diversion. To prevent unauthorized use, disposal of the drugs must be witnessed and appropriately documented by 1 or more additional staff member trained in medication safety.

Special Considerations for Emergency Medications

Safe utilization of emergency medications can be more difficult as these drugs are used infrequently and are likely to be less familiar to the provider. In order to reduce medication errors in emergency drug administration, a conscious effort must be made to thoroughly understand these agents. Periodic review of emergency management by all individuals involved with patient care is necessary. Emergency drills should be practiced monthly and along with reviewing the proper steps to take in a potential crisis event, the staff should discuss the use of any indicated emergency drugs. They should be familiar with the type of emergency drugs used in each scenario, location of each drug, when it will be utilized, and how it will be administered. The more prepared and familiar the team is with emergency management, the more likely it is that adverse outcomes can be avoided.

It is widely accepted that memory worsens during stressful events, so relying strictly on cognitive ability to recall vital drug information during an emergency is inherently problematic. Users of the ADSA Ten Minutes Saves a Life! app will be directed through the proper emergency management steps including use of the applicable emergency drugs along with initial and subsequent dosing recommendations. The app can track drug dosages and administration times and alert the user to potential overdose. It also has as a comprehensive database of emergency drugs that can be accessed at any time to retrieve the manufacturer's drug information including recommended and maximum dosing information (Image 5).

Image 5.

Manufacturer's drug information page within the ADSA Ten Minutes Saves a Life! mobile app.

Visual aids are another option to provide assistance during emergency events. Having a small card with the medication vial that lists information including its action, appropriate dose, maximum dose, as well as indications, contraindications, and side effects can be a potentially lifesaving resource mitigating medication errors. If a drug requires dilution prior to administration, a special label should be placed on the vial and the appropriate protocol for preparing the agent should be included on the card. The preparation of emergency drugs using expired drugs should be practiced regularly by all anesthesia providers.

During anesthetic and medical emergencies, the use of appropriate medications and dosages is crucial. Appropriate practice and simulation of emergencies can help to optimize outcomes by improving responses during this critical time. Emergency algorithms are beneficial in helping choose the proper medication and dose, as well as reducing the accidental omission of a critical agent or action. The ADSA Ten Minutes Saves a Life! emergency manual application is specifically designed to assist in the management of sedation and anesthesia emergencies. In the case of an emergency, the app directs the user to the appropriate emergency drug and auto calculates the appropriate and maximum dosage based on the patient's prepopulated weight, allergies, and other pertinent information. In pediatric cases, providers can also use a pediatric emergency drug calculator or a Broselow Pediatric Emergency Tape (eBroselow, Southborough, MA), although the tape strip is less accurate than the drug calculator as it uses the child's height instead of body weight to determine the dosage.

Summary

Delivering anesthesia for dentistry in a safe and effective manner within the office-based dental environment is a key component to providing optimal dental care for patients. Dentists who utilize sedation and/or general anesthesia must focus on optimizing medication safety to reduce the incidence of medication errors and adverse drug events. Use of the DAMSP and implementing practical safety initiatives in dental facilities can greatly reduce the number of medication errors that occur in dentistry. Ongoing medication safety education and training are essential steps in reducing potentially life-altering, preventable errors. Improving the culture of medication safety is essential and requires the attention of all individuals involved in providing sedation and general anesthesia for dentistry.

CONTINUING EDUCATION QUESTIONS

This continuing education (CE) program is designed for dentists who desire to advance their understanding of pain and anxiety control in clinical practice. After reading the designated article, the participant should be able to evaluate and utilize the information appropriately in providing patient care.

The American Dental Society of Anesthesiology (ADSA) is accredited by the American Dental Association and Academy of General Dentistry to sponsor CE for dentists and will award CE credit for each article completed. You must answer 3 of the 4 questions correctly to receive credit.

Submit your answers online at www.adsahome.org. Click on ‘‘On Demand CE.''

CE questions must be completed within 3 months and prior to the next issue.

1. The incidence of drug administration errors:

   1. is largely due to a single factor—syringe and drug labelling—that lacks standardization.

   2. is largely underreported due to the anesthesia provider being unaware that a mistake has been made.

   3. is not improved by utilization of prefilled syringes instead of reliance of individuals drawing medications from multiple-dose vials.

   4. is trending significantly downward in medicine and hospital-based care due to institutional safeguards.

2. In order to reduce drug administration errors, regularly scheduled simulated emergencies should ideally be:

   1. conducted at least quarterly to establish a culture of safety.

   2. focused on airway compromise as the most common contributing element to patient harm.

   3. individualized to a single practitioner rather than staff or assistants.

   4. performed at least once per year.

3. The responsibility of ensuring overall patient safety can be delegated to surgical assistants and staff in dental settings as they are under direct supervision of the operating dentist or surgeon.

   1. True

   2. False

4. During emergency situations, which of the following human factors in drug administration error can be mitigated with a mobile app, such as the ADSA Ten Minutes Saves a Life!?

   1. Confusion regarding emergency drug location and delegating retrieval to individual surgical team members

   2. Lack of recognition of the drug vial needed for resuscitation

   3. Lapses in memory for correct dosing of a reversal medication

   4. Practitioners being overburdened with the cognitive tasks of proper diagnosis, directing resuscitative efforts, and ensuring task completion