Organization Promotes Safety: A Step Forward

  • Kimberly A. Pollock
  • Jonathan L. Benumof


This chapter outlines the accidental instillation of lidocaine instead of bupivacaine into the intrathecal space in a healthy patient undergoing a cesarean section. Luckily, no adverse outcome was noted; however, not all syringe swaps are so benign. With patients living longer and disease processes becoming more advanced, anesthetic management has become more complicated. Multiple drugs may be drawn up rapidly in order to acutely manage a sick patient. With the growing need for efficiency in the operating room comes the increased risk of drug errors, accidental needlestick injuries, and contamination. In order to protect both the patient and the provider from these hazards, a well-organized and systematic approach that addresses the potential for error at all stages is necessary. This chapter proposes a standardized way to organize drugs for a basic general anesthetic case, syringes and instruments for placing central venous catheters, as well as offers a unique approach for organizing the spinal and epidural trays in a way that should theoretically decrease these potential hazards. It is important to note that the most crucial aspect of establishing patient and provider safety in the workplace is having a method that is well thought out and practiced routinely by its providers.


Definition drug error Syringe swap Drug container swap Labeling error Colossal error Incidence Factors Drugs in error Cross-contamination Needlestick injury Potential error times Drug drawer problems Drug drawer solutions Syringe sizes Drug labels The geography of location Tabletop workstation Cart workstation Above the tabletop workstation Plunger label Central venous catheter tray Needle gauge and hub Syringe layout Spinal tray Epidural tray 


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Kimberly A. Pollock
    • 1
  • Jonathan L. Benumof
    • 2
  1. 1.Department of AnesthesiologyUniversity of CaliforniaSan DiegoUSA
  2. 2.Department of AnesthesiologyUniversity of California, UCSD Medical Center, UCSD School of MedicineSan DiegoUSA

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