CONTINUING EDUCATION IN MEMORY OF NORMAN TRIEGER, DMD, MD

Medication Safety: Reducing Anesthesia Medication Errors

and Adverse Drug Events in Dentistry Part 2
Daniel S. Sarasin, DDS,† Jason W. Brady, DMD,‡§ and Roy L. Stevens, DDSjj
†Private Practice, Oral and Maxillofacial Surgery, Cedar Rapids, Iowa ‡Private Practice, Dental Anesthesiology, Phoenix, Arizona §Attending
Faculty, Dental Anesthesiology, New York University Langone Health, New York City, New York jjPrivate Practice, Special Care Dentistry of
Oklahoma, Oklahoma City, Oklahoma

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).

Key Words: Medication safety; Medication errors; Adverse drug events; Dental anesthesia and sedation;
Dentalpatient safety.

ith the recent increase in national attention
W 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
Received July 15, 2019; accepted for publication July 26, 2019.
Address correspondence to Dr Daniel S. Sarasin, 835 3rd Ave SE,
Cedar Rapids, IA 52403; d.sarasin@mchsi.com.
Anesth Prog 67:48–59 2020 j DOI 10.2344/anpr-67-01-10
Ó 2020 by the American Dental Society of Anesthesiology
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. Reduc-
ing 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 inappro-

48
Anesth Prog 67:48–59 2020
priate 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 unpredict-
able 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 Univer-
sity 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 administra-
tion 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
Sarasin et al 49
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.
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.
Fortunately, research efforts to recognize the inci-
dence, 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. Interest-
ingly, 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 anes-
thesia in 1848.11 In 2004, Jensen et al12 developed 1
50 Reducing Anesthesia Medication Errors and Adverse Drug Events Part 2 Anesth Prog 67:48–59 2020

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.

general and 5 specific strong evidence-based recommen-
dations for reducing drug administration errors during
anesthesia from a systematic review of the literature
(Table 2).
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 Standardiza-
tion, 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
Anesth Prog 67:48–59 2020
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
well as 6 guidelines or sets of initiatives regarding
medication safety by national and international organi-
zations. 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.
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 SleepSysteme; Safer Sleep, LLC,
Auckland, NZ) versus conventional methods on reduc-
ing 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 administra-
tion 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,
Sarasin et al 51
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 envi-
ronment 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
52 Reducing Anesthesia Medication Errors and Adverse Drug Events Part 2
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
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 initia-
tives 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. Anesthe-
sia 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 anes-
thesia 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.
Improve the Culture of Medication Safety
Improving medication safety starts with a heightened
awareness that medication errors and adverse drug
Anesth Prog 67:48–59 2020
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).
Incorporating formalized regularly scheduled simu-
lated 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 optimiz-
ing the culture regarding medication safety provide
Anesth Prog 67:48–59 2020 Sarasin et al 53

Image 1. Emergency algorithms selection page within the ADSA Ten Minutes Saves a Life! mobile app.
54 Reducing Anesthesia Medication Errors and Adverse Drug Events Part 2
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
Anesth Prog 67:48–59 2020
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).
Medication pharmacokinetic and pharmacodynamic
variations between age groups must be appreciated to
safely administer sedation and anesthesia. These differ-
ences 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, hor-
mones, 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 pharmaco-
dynamics often necessitating adjustments to adminis-
tered drugs.
Improve Management of Anesthesia and Emergency
Medications
Increasing medication safety requires appropriate man-
agement 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. Medica-
tion 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 concentra-
tion 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 environ-
Anesth Prog 67:48–59 2020
Image 2. Drug expiration page within the ADSA Ten Minutes Saves a Life! mobile app.
ment 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 prepara-
tion 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 prepara-
tion may be necessary. Overheating or freezing of the
medication prior to or during transport can occur.
Inspection of the drug vials for damage and contami-
nation 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 Enforce-
ment 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.
Sarasin et al 55
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 require-
ments. 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 trans-
port, 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 con-
fused drugs (Images 3 and 4). Additional markings
made on the vial’s flip top can help differentiate similar
56 Reducing Anesthesia Medication Errors and Adverse Drug Events Part 2
Images 3 and 4. Ephedrine and epinephrine drug labels
illustrating ‘‘tall man’’ lettering.
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.
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 infec-
tion 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
Anesth Prog 67:48–59 2020
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, concentra-
tion, 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 docu-
mentation, 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 anes-
thesia, 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 some-
thing’’ 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 unautho-
rized 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 adminis-
Anesth Prog 67:48–59 2020
Image 5. Manufacturer’s drug information page within the ADSA Ten Minutes Saves a Life! mobile app.
tration, 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
Sarasin et al 57
database of emergency drugs that can be accessed at any
time to retrieve the manufacturer’s drug information
including recommended and maximum dosing informa-
tion (Image 5).
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 administra-
tion, 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. Appro-
priate 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
58 Reducing Anesthesia Medication Errors and Adverse Drug Events Part 2
action. The ADSA Ten Minutes Saves a Life! emergency
manual application is specifically designed to assist in
the management of sedation and anesthesia emergen-
cies. 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, South-
borough, 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.
References
1. National Coordinating Council for Medication Error
Reporting and Prevention. What is a medication error? Available
at: https://www.nccmerp.org/about-medication-errors. Published
2015. Accessed September 19, 2016.
2. Institute of Medicine Committee on Quality of Health
Care in America. In: Kohn LT, Corrigan JM, Donaldson MS,
eds. To Err is Human: Building a Safer Health System.
Washington, DC: National Academies Press; 2000.
3. Grigg EB, Roesler A. Anesthesia medication handling
needs a new vision. Anesth Analg. 2018;126:346–350.
4. Beecher HK, Todd DP. A study of the deaths associated
with anesthesia and surgery: based on a study of 599, 548
anesthesias in ten institutions 1948–1952, inclusive. Ann Surg.
1954;140:2–35.
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5. Cooper RL, Fogarty-Mack P, Kroll HR, Barach P.
Medication safety in anesthesia: epidemiology, causes, and
lessons learned in achieving reliable patient outcomes. Int
Anesthesiol Clin. 2019;57:78–95.
6. Abrishami A, Correa J, Abrahamyan L, et al. Medica-
tion errors in patients under general anesthesia: a systematic
review. Anesthesia Analgesia. 2018;126:486.
7. Hicks R, Becker S, Cousins D. MEDMARX data
report: a chartbook of medication error findings from the
perioperative settings from 1998–2005. Rockville, MD: USP
Center for the Advancement of Patient Safety; 2006.
8. Cooper L, Nossaman B. Medication errors in anesthe-
sia: a review. Int Anesthesiol Clin. 2013;51:1–12.
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Evaluation of perioperative medication errors and adverse
drug events. Anesthesiology. 2016;124:25–34.
10. Leahy IC, Lavoie M, Zurakowski D, Baier AW,
Brustowicz RM. Medication errors in a pediatric anesthesia
setting: Incidence, etiologies, and error reduction strategies. J
Clin Anesth. 2018;49:107–111.
11. Snow J. On the fatal cases of inhalation of chloroform.
Edinb Med Surg J. 1849;72:75–87.
12. Jensen LS, Merry AF, Webster CS, Weller J, Larsson L.
Evidence-based strategies for preventing drug administration
errors during anaesthesia. Anaesthesia. 2004;59:493–504.
13. Eichhorn J. APSF Hosts Medication Safety Conference:
Consensus Group Defines Challenges and Opportunities for
Improved Practice. APSF Newsletter. 2010;25:1–7.
14. Wahr JA, Abernathy JH 3rd, Lazarra EH, et al.
Medication safety in the operating room: literature and
expert-based recommendations. Br J Anaesth. 2017;118:32–
43.
15. Merry AF, Webster CS, Hannam J, et al. Multimodal
system designed to reduce errors in recording and administra-
tion of drugs in anaesthesia: prospective randomised clinical
evaluation. BMJ. 2011;343:d5543.
16. Grigg EB, Martin LD, Ross FJ, et al. Assessing the
impact of the anesthesia medication template on medication
errors during anesthesia: a prospective study. Anesth Analg.
2017;124:1617–1625.
17. Yang Y, Rivera AJ, Fortier CR, Abernathy JH 3rd. A
human factors engineering study of the medication delivery
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syringes. Anesthesiology. 2016;124:795–803.
18. Martin LD, Grigg EB, Verma S, Latham GJ, Ramper-
sad SE, Martin LD. Outcomes of a failure mode and effects
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Anesth Prog 67:48–59 2020 Sarasin et al 59

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:
a. is largely due to a single factor—syringe and drug
labelling—that lacks standardization.
b. is largely underreported due to the anesthesia
provider being unaware that a mistake has been
made.
c. is not improved by utilization of prefilled syringes
instead of reliance of individuals drawing medi-
cations from multiple-dose vials.
d. 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:
a. conducted at least quarterly to establish a culture
of safety.
b. focused on airway compromise as the most
common contributing element to patient harm.
c. individualized to a single practitioner rather than
staff or assistants.
d. 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.
a. True
b. 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!?
a. Confusion regarding emergency drug location
and delegating retrieval to individual surgical
team members
b. Lack of recognition of the drug vial needed for
resuscitation
c. Lapses in memory for correct dosing of a reversal
medication
d. Practitioners being overburdened with the cogni-
tive tasks of proper diagnosis, directing resusci-
tative efforts, and ensuring task completion