Medication Handling

Shohreh Sadlou

Corey Sippel

▪ INTRODUCTION

Traditionally, dedicated operating room (OR) pharmacists and pharmacy activities within the OR setting were viewed as luxury items. In the past, OR drug storage, preparation of intravenous (IV) medications, and narcotic record keeping were performed by nursing personnel and anesthesia staff. However, in recent years, OR pharmacies have become a necessity to facilitate medication handling in busy ORs. The driving forces that prompted the creation of on-site OR pharmacies were the need for improved accountability of controlled substances and the reduction of medication errors. Cost containment, reducing waste of unused medications, efficient drug distribution, enhancing accuracy in patient billing, and providing clinical pharmacy information are additional benefits of establishing OR pharmacies

ORs are the most medication-intensive areas in the hospital, and anesthesia technicians should be familiar with medication handling. Developing and maintaining a strong foundation for medication management processes in the OR is largely dependent on multidisciplinary cooperation between OR pharmacists, anesthesiologists, anesthesia technicians, nursing staff, and OR managers. This chapter focuses on safe and efficient medication handling and highlights some of the regulatory issues in this area.

▪ CONTROLLED SUBSTANCES ACCOUNTABILITY

Easy access to opioids in the perioperative environment has resulted in numerous cases of abuse. Of note, anesthesiologists make up about 3% of the physician workforce but account for 13% of physicians treated for substance abuse. Because of the potential for abuse of certain medications, the U.S. Food and Drug Administration (FDA) has classified them as “controlled substances.” These medications have special regulations for handling and prescribing. Controlled substances play a crucial role in surgery and anesthesia, but because of potential diversion and abuse, their use in the OR falls under strict control and accountability procedures defined by the FDA and state law. Controlled substances are categorized into five distinct schedules:

Schedule I Controlled Substances: They have the highest potential for abuse, with no accepted medical use. Examples of this class of drugs are heroin and lysergic acid diethlamide (LSD).
Schedule II Controlled Substances: They have a high potential for abuse, but with accepted medical use. Schedule II controlled substances are most commonly used in OR settings. Examples of this class of drugs are fentanyl, hydromorphone (Dilaudid), morphine, and cocaine (used as a topical anesthetic).
Schedule III Controlled Substances: They have a potential for abuse less than the drugs or other substances in schedule I or II. Drugs in this class have accepted medical use. Examples of drugs in this class are anabolic steroids and ketamine.
Schedule IV Controlled Substances: They have a low potential for abuse with accepted medical use. Examples of this class are benzodiazepines, such as alprazolam (Xanax), diazepam (Valium), and midazolam (Versed).
Schedule V Controlled Substances: They have a low potential for abuse relative to the drugs and other substances in schedule IV and have accepted medicinal use. Examples of this class are pregabalin (Lyrica) and cough suppressants with small amounts of codeine.

Hospitals have adopted different methods of dispensing controlled substances in accordance with state and federal regulations. Policy and procedures should be written by the pharmacy
department covering the safe handling of controlled substances in the OR. Anesthesia technicians should follow state and federal regulations, as well as institutional policies, when asked to retrieve any medication or assist with the administration of a medication.

The most common methods of dispensing controlled substances to the anesthesia providers are as follows:

Manual recording: Manual recording is still used in many facilities and involves signing out a box or specific quantity of controlled substances to an anesthesia provider, who then records the dosages given to a patient. The wastage of controlled substances can be performed at the end of each case by the provider and witnessed by a licensed OR nurse. Documentation of the wastage then needs to be cosigned by the provider and the OR nurse.
Password-protected, automated devices such as the Pyxis MedStation dispense controlled substances for each individual patient to a nurse or a physician. Wastage and return of intact vials of controlled substances should be performed via the automated device.
Some ORs have dedicated pharmacies to increase control and accountability. Controlled substances are obtained by submitting a Controlled Substance Request Form to the pharmacy. The form is patient specific and is filled out by the anesthesiologist. Removal of all controlled substances, return of controlled substances, and wastage of controlled substances are documented in this form. Controlled substance use is audited by comparing the Controlled Substance Request Form against the anesthetic records. This procedure allows the OR pharmacist to reconcile the amount of each controlled substance issued to each anesthesiologist with the amounts given to the patient (based on anesthetic records), returned to the pharmacy, or wasted in the pharmacy. Any amount of controlled substances not accounted for in one of these three categories will be flagged as a discrepancy or loss. The anesthesia provider would then be contacted by the pharmacy to reconcile any discrepancies.

Returns of controlled substances that have been drawn into syringes but not used are randomly tested to make sure that there has not been any tampering with the original concentrations of the controlled substance. Any discrepancies that are found are reported to the chairman of the department of anesthesiology or as specified in the institution’s policy and procedures.

▪ REDUCING MEDICATION ERRORS DURING ANESTHESIA

In an analysis of critical events during anesthesia, medication-related events (e.g., syringe swaps, drug ampoule swaps, overdoses, and incorrect drug choices) were the most frequent problem. Drug administration errors are estimated to occur in 1 out of every 133 anesthesia cases.

Factors increasing the risk of medication errors during anesthesia include the following: