Managing medication use inthe operating room is chal-lenging for any hospital,whether it is a 700-bedurban teaching hospital or a

100-bed rural community hospital. In addi-tion to the unique issues each facility faces,there is the common challenge of ensuringnecessary access to medication without sacri-ficing the control required to ensure regula-tory compliance, medication security, andpatient safety. There remains a delicate bal-ance between providing convenient, flexible,and timely medication access and theseincreasingly complex and stringent medica-tion control mechanisms.

At the University of Maryland MedicalCenter (UMMC), Baltimore, we constantlystrive to achieve that optimum balancebetween access and control. Success in meet-ing this goal depends upon prudent employ-ment of technology, executing well-con-ceived operational policies and procedures,and maintaining effective relationships withkey stakeholders.

Role of TechnologyImplementing computerized prescriber medication order entry(CPMOE) at UMMC has resulted in significant medication safetyimprovements. Though the OR is not within the scope of ourCPMOE program, the use of order sets, one of CPMOE’s hallmarkfeatures, was translated to support safe medication practices in theperioperative process. We make transplant induction order sets avail-able, which comprise the medications used for organ transplantation:immunosuppressant agents, antibiotics, and induction agents. Thetransplant team is thus able to simply choose the necessary medica-tions based upon the type of transplant being performed. Post opera-tive order sets are also available. These order sets are customizedaccording to the type of surgery performed and serve to prompt thephysician to continue antibiotics post operatively, a measure crucialfor infection prevention.

The use of automated dispensing cabinets(ADCs) in the OR supports medication con-trol and access therein. With an ADC in eachsuite, anesthesiologists and nurse anesthetistsretrieve medications directly from the cabinet,avoiding the inconvenience and delay associat-ed with requesting and retrieving medicationsfrom the OR pharmacy. The ADCs track themedications that are withdrawn, generatepatient charges, and produce valuable reports.For example, the core replenishment report isutilized daily for restocking any medicationsthat have been depleted from the cabinet. Inaddition, a monitoring report is generateddaily, allowing for managerial review of techni-cian activity to ensure the ADCs are checkedmonthly for expired medications. The reportindicates which medications have beenchecked and by whom.

Operational PoliciesOur operational policies and proceduresdemonstrate our commitment to safe medica-tion practices. These policies and proceduresinclude appropriate packaging of hazardousproducts, the provision of medications in sur-

gery-specific kits, and the development of a nurse-friendly labeling sys-tem. For example, glutaraldehyde, a carcinogenic agent and haz-ardous material, is used during cardiac surgery to wash pericardial tis-sue and valves. In the past, our nurses lacked a safe method for dis-pensing and disposing of this product. To protect the surgical staff,the pharmacy agreed to package the product in one mL aliquots,allowing the surgical team to request the exact amount required foreach surgery. Pharmacy technicians now package glutaraldehyde froma bulk container into individual aliquots within a chemotherapy glove-box. The nurses appreciate this change as they can simply order theproper amount of aliquots from the pharmacy, and the bulk bottlesare no longer stored in the cardiac suite.

We are also able to provide some medications to the OR nurses viasecure medication kits. Each medication kit is designed to meet theneeds of a specific type of patient; for example, we prepare general

PHARMACY&Purchasing Products

As Seen InApril 2009 Vol. 6 No. 4

By Meagan Rushe, PharmD

Medication Managementin the Operating Room

The use of automated dispensing cabinets(ADCs) in the OR supports medication

control and access therein.

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OR kits, neuro-surgery kits, pediatric nursing kits, and others. The kitsare double-checked by a pharmacist or a pharmacy technician, whosigns the check sheet and secures the kit with a red lock. The kit-checkprocess includes checking each item’s expiration date and document-ing on the check sheet any medications set to expire within sixmonths. OR pharmacy personnel dispense the kits to the nurses andcollect any used kits for reprocessing. Using a sign-out sheet, the nurs-es indicate the kit’s planned destination, allowing for easy monitoringof each kit’s location. In addition, a charge sheet accompanies eachkit, ensuring complete and accurate billing.

The importance of properly labeling the basins used in the sterilefield during surgery cannot be understated as the basins can be easilyconfused. For example, a basin containing an antibiotic mixture, suchas bacitracin for irrigation, can easily be mistaken for a basin contain-ing normal saline. Just as medications can be confused, the basins canalso be confused, underscoring the need for appropriate labeling. Ourpharmacy department provides OR nurses with standard medicationlabeling nomenclature, which mimics the nomenclature used in theCerner Millennium Pharmnet computer system and in the OmnicellADC system employed at UMMC.

In addition to promoting safe medication practices, the OR phar-macy dispenses pre-mixed medications and mixes patient-specificmedications in the pharmacy to avoid common medication prepara-tion errors. Items that are distributed as pre-mixed, or pharmacy-mixed preparations include antibiotics, such as vancomycin andciprofloxacin; and irrigations, such as bacitracin and clindamycin.Items are also prepared upon request, such as ropivacaine for the On-Q pumps. Additionally, the pharmacy provides medications in pre-filled syringes for anesthesia use, including rocuronium, succinyl-choline, methadone, and fentanyl. Providing these medications in pre-

filled, properly labeled syringes reduces the potential for error thatcould result from an omitted label or an incorrectly labeled syringe.

To reduce the potential for errors when ordering and preparingchemotherapeutic agents—particularly errors resulting from illegiblehandwriting and inappropriate deviations from standard protocols—pharmacy created preprinted order forms for a majority of the stan-dard protocols. The physicians access the catalog through the hospi-tal’s intranet, select and print the required form, and adjust the con-tents if appropriate. When a chemotherapy agent is needed during sur-gery, these forms ensure consistency of approach between the ORpharmacy and the oncology satellite pharmacy, where our chemother-apy medications are prepared. This system provides many of the samesafety features of CPMOE for chemotherapy orders.

Management PhilosophyInstituting and maintaining successful medication managementprocesses in the OR pharmacy requires developing excellent interdis-ciplinary relationships. At UMMC, the OR-suite ADCs are effectivebecause of the collaborative efforts be tween pharmacy staff and anes-thesiologist, Dr. David Schreibman. His support was key in imple-menting the program and is essential to the continuous improvementof the program. The recent opening of a new OR suite underscoresthe impact of effective working relationships on operational success.The new area is remote from the existing OR area, which presentsunique medication management challenges, such as ensuring commu-nication and collaboration, and timely delivery. However, the samemulti-disciplinary cooperation that contributed to a successful open-ing now contributes to ongoing success. This multi-disciplinary coop-eration includes the involvement of charge nurses, nurse managers,and participation in perioperative quality council meetings.

Future DirectionThe pharmacy is continuously searching for ways to improve its servic-es. Goals include expanding the medications available to anesthesia inpre-filled, labeled syringes, and refining ADC processes to better servethe anesthesia practitioners. Our technology bent, operational poli-cies and procedures, and management philosophy of establishingeffective relationships provide a solid foundation for continuous med-ication safety improvements in the OR. �

Meagan Rushe, PharmD, is the manager of the shocktrauma and operating room pharmacy satellites at theUniversity of Maryland Medical Center, where she beganher career as a clinical pharmacist. Meagan received her

doctor of pharmacy degree from the University of Pittsburgh Schoolof Pharmacy in April 2007.

Reprinted with permission from Pharmacy Purchasing & Products, Vol. 6 #4. ©2009 Ridgewood Medical Media, LLC, Ho-Ho-Kus, NJ. All rights reserved.

The importance ofproperly labeling the basins

used in the sterile field during surgery cannot be

understated as the basins can be easily confused.

Tel: 800-850-6664E-mail: info@omnicell.com