Table Of ContentMedication Safety
during Anesthesia and
the Perioperative Period
HEHBYANDJOYCEWABN
Medication Safety during
Anesthesia and the
Perioperative Period
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Medication Safety during
Anesthesia and the
Perioperative Period
Alan Merry
University of Auckland and Auckland City Hospital
Joyce Wahr
University of Minnesota
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DOI: 10.1017/9781108151702
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First published 2021
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A catalogue record for this publication is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Merry, Alan, author. | Wahr, Joyce, 1952- author.
Title: Medication safety during anesthesia and the perioperative period/Alan Merry, Joyce Wahr.
Description: New York : Cambridge University Press, 2020|Includes bibliographical references and index.
Identifiers: LCCN 2020026694 (print) | LCCN 2020026695 (ebook)|ISBN 9781107194106
(hardback)|ISBN 9781108151702 (ebook)
Subjects: MESH: Anesthetics--adverse effects | Medication
Errors--prevention & control | Anesthesia--methods | Anesthesia--adverse effects | Perioperative Period
Classification: LCC RD82.2 (print) | LCC RD82.2 (ebook) | NLM QV 81|DDC 615.7/81--dc23
LC record available at https://lccn.loc.gov/2020026694
LC ebook record available at https://lccn.loc.gov/2020026695
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Every effort has been made in preparing this book to provide accurate and up-to-date information that
is in accord with accepted standards and practice at the time of publication. Although case histories are
drawn from actual cases, every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors, and publishers can make no warranties that the information contained
herein is totally free from error, not least because clinical standards are constantly changing through
research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or
consequential damages resulting from the use of material contained in this book. Readers are strongly
advised to pay careful attention to information provided by the manufacturer of any drugs or equipment
that they plan to use.
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Cover image caption
On first looking at the image on the cover of this book, one can readily imagine an anesthesiologist, wear-
ing a mask, taking care in drawing up a medication from a vial for intravenous injection into a patient in
the operating room. On close inspection, failures in safety can be identified. Thus, this image symbolizes
the serious need for improvement in medication safety in anesthesia and the perioperative period, in the
system and also in the practices of many of the clinicians who work within it.
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This book is for the patients whom we as a profession have harmed
through medication errors and for their loved ones, particularly those
who are bereft forever because of these errors. It is also for those idealistic,
dedicated, and compassionate people who (like us) work in healthcare and
who (like us), in spite of their very best efforts and to their deep distress,
have inadvertently harmed the very patients they have been trying so hard
to help. We hope it will contribute to making the use of medications in
anesthesia and the perioperative period a little safer for everyone.
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The Snow Vaporizer, Mark II inhaler which I employ, the compartment con-
taining the chloroform is surrounded with cold
water to limit the quantity of vapour taken up by
John Snow was the first physician to specialize
the air, and the expiratory valve of the face piece
in the administration of anesthesia. He care-
is so adapted as to admit additional air to further
fully investigated the first 100 deaths due to
dilute the vapour.”
chloroform and performed an in-depth analy-
The pictured inhaler is termed the “Mark II,”
sis of the vaporization characteristics of chloro-
showing the water bath, and a stopcock to control
form. He found a very narrow margin between
the amount of vapor being administered. Only
the concentration that provided anesthesia (5%)
two examples of this inhaler survive today; this
and the concentration that produced cardiac
one is in the archives of the American Society of
paralysis and death (10%). In his comments to
Anesthesiologists.
the Westminster Medical Society on March 31,
Image courtesy of the Wood Library-Museum of
1849, Dr. Snow described his attempt to improve
Anesthesiology, Schaumberg IL.
anesthesia safety through better design: “In the
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Contents
Foreword xi
Acknowledgments xiii
1 Introduction to Medication Safety 10 Medication Safety in Special
in Anesthesia and the Perioperative Contexts 191
Period 1
11 Legal and Regulatory Responses to
2 Failures in Medication Safety during Avoidable Adverse Medication Events,
Anesthesia and the Perioperative Part I: General Principles 215
Period 18
12 Legal and Regulatory Responses to
3 Failures in Medication Safety in the Avoidable Adverse Medication Events,
Intensive Care Unit and Ward 43 Part II: Practical Examples 236
4 Impact of Medication Errors on the Patient 13 Barriers to Improving Medication Safety:
and Family: Managing the Aftermath 56 Why Is Patient Safety So Hard? 265
5 Consequences for the Practitioner 68 14 Conclusions 281
6 Why Failures Occur in the Safe
Management of Medications 87
7 Errors in the Context of the Perioperative Index 285
Administration of Medications 106
8 Violations and Medication Safety 130
9 Interventions to Improve Medication
Safety 156
ix
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Foreword
In this day and age of hyperelectronic information tribulations associated with implementing them in
feeds, 140-character tweets, viral YouTube v ideos, their own institutions. In addition, each author has
Instagram images and stories, and an endless conga extensive experience in national and international
line of podcasts, it is refreshing to find a full text leadership positions and has learned the difficul-
that can capture and hold your attention. This is ties – and appreciated the joys – associated with
particularly true when the text provides remark- successful implementation of medication safety
able insights into important issues. In this new initiatives. Their authenticity rings true through-
text by Drs. Alan Merry and Joyce Wahr, we get the out the text.
benefit of their years of astute observation and pas- The text is unique in that it includes crucial
sionate leadership in perioperative patient safety. chapters that address the long-term sequelae and
Their text, Medication Safety during Anesthesia and impact of medication safety issues, including
the Perioperative Period, is keenly written, sharply errors, on patients and families as well as health-
pointed, and laser-focused on the broad issues care professionals who work in the perioperative
impacting and impacted by medication safety. period. Their use of case studies to illustrate the
There are few important new texts written solo impact of patient harm on everyone involved is
or by a small team of authors – and with this text, we both clinically relevant and personally moving.
get the benefit of a two-author tome that has a con- Overall, it is a text that tells a compelling story
cise writing style, consistency in formatting, and a of the impact of medication errors and system-
strong interlinking of principles from chapter to atic problems that arise within the complexities of
chapter. Common themes are interwoven through medication administration.
the diverse chapters, providing bundled insights Drs. Merry and Wahr have provided us with the
that build on each other in a way that few multiau- insights and information we need to excel locally
thored texts do. This stacking of ideas and observa- as well as within larger-scale health systems to
tions augments their observations and strengthens improve medication safety. This text is a tribute
their recommendations. It is an ideal approach for to their expertise, their real-life experiences in
two authors who bring so much knowledge and patient safety, and their remarkable storytelling.
expertise to their writing. Our patients deserve our best efforts, and this text
Drs. Merry and Wahr observe locally but think provides us with the knowledge to make a differ-
globally. They have a wealth of national as well as ence in their safety. Hearty congratulations to Drs.
international experiences, with each having spent Merry and Wahr!
their professional lives engaged in the promotion
of anesthesia and perioperative patient safety. Their Mark A. Warner, MD, President
observations have involved the local development Anesthesia Patient Safety Foundation
of medication safety initiatives and the trials and
xi
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Acknowledgments
We are very grateful to Mia Jüllig, of Paper Dog Mead, Dr. John Villiger, Dr. Matthew Moore, Mrs.
Ltd (www.paperdog.co.nz), for creating clear, Debbie Beaumont, and Mr. Michael Merry. We are
accurate, and usable illustrations from various grateful to Dr. Mark Warner for providing us with
sources including, in particular, our own some- such an excellent Foreword. We would particularly
what arcane suggestions. We would also like to like to thank our publisher, Jessica Papworth, who
express our very sincere thanks to the following has been amazingly understanding, helpful, and
people who have each made invaluable contribu- encouraging during the prolonged gestation of this
tions to this book, through support, advice, dis- book. Finally, we cannot adequately express our
cussion, the provision of information, and the gratitude to Dennis Wahr, Sally Merry, and many
review of chapters: Professor Michael Wall, Dr. other members of our two families for their unfail-
Karen Domino, Professor Robin Ferner, Mr. John ing support of this project.
xiii
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