Variation in medicines on anaesthesia carts in operating rooms

Editor, Although the required anaesthesia equipment in an operating room is described extensively,1 this is not the case for anaesthesia-related drugs. Up to 87% of medication errors are due to human factors and lack of organisational structure.2 Furthermore, errors due to drug ampoule swaps are listed in the top 10 of frequent critical incidents.3 To reduce these errors, a standardisation of the medicine drawer of the anaesthesia cart has been suggested.2–4 Literature provides several initiatives. Libman compiled a list containing drugs and equipment recommended for the anaesthesia cart.5 Merry et al.6 made recommendations based on, for instance, the type of procedures carried out in a centre. The American Association of Nurse Anesthetists created a list for general anaesthesia carts and the Association of Anaesthetists of Great Britain & Ireland (AAGBI) has created The National Essential Anaesthesia Drug List. However, the purpose of this list is to give advice on what is essential to ensure sustainability of supply. The aim of this study was two-fold: first, to investigate whether guidelines regarding medicines that should be present on anaesthesia carts exist; and second, to create an overview of the medicines present on anaesthesia carts in operating rooms in the Netherlands. We contacted anaesthesiologists in Belgium, Brazil, Canada, Germany, Spain, Switzerland, the United Kingdom and the United States of America. We e-mailed the American Society of Anesthesiologists, the AAGBI, the Dutch Society of Anaesthesiologists and the European Society of Anaesthesiology. In addition, an internet search was performed to see if the Australian and New Zealand College of Anaesthetists, the Chinese Society of Anesthesiology and the World Federation of Societies of Anaesthesiologists offered guidelines. None were found. Eighty out of 128 hospitals in the Netherlands responded to the question about which medicines are present on their anaesthesia carts. 116 different medicines were reported. Medicines were grouped into 10 groups according to their primary mode of action. In Table 1, the reported medicines are presented, ranked in order of occurrence. A median of 39 medicines (range 27 to 59) were in stock on anaesthesia carts. Only two medicines were present in all hospitals: that is dexamethasone and propofol. In addition, our results showed a large variation among hospitals regarding medicines present on anaesthesia carts. Furthermore, drugs that are frequently used in emergency settings were not always present on the anaesthesia cart. For instance, epinephrine was absent on anaesthesia carts in 15% of the centres.Table 1: Reported medicines, grouped (according to their primary mode of action) and in order of occurrence on anaesthesia carts in hospitals in the Netherlands (%)For some medicines, a difference in manner of storage can explain the observed differences. A prime example is rocuronium, sometimes placed in a cooled compartment built into the wall of operating rooms while in other hospitals a number of ampoules are taken every morning from the central storage facility. Some hospitals also use different anaesthesia carts stocked with medicines for specific surgical procedures. The contents of these carts were not incorporated into this study. This, and the fact that not all hospitals perform the same medical procedures, might partly explain the variation in appearance of medicines. A total of 18 antibiotics were encountered, accounting for roughly 15% of the medicines reported. This is due to different antimicrobiotic protocols and different policies regarding the time of admittance of antibiotics. Some hospitals administer the antibiotics before patients arrive in the operating room, rendering the presence of antibiotics on the anaesthesia cart redundant. A variety in medicines present on anaesthesia carts could have negative influence on patient safety. To standardise medication drawers Shultz et al.7 had anaesthesia professionals design a medicine drawer for the anaesthesia cart that would be, in their opinion, most useful to work with. Ultimately, one medicine drawer was formed and is currently being used in two hospitals. Future research will have to elucidate whether this actually reduces the amount of medication errors. Summarising, no national or international guidelines regarding which medicines are recommended for anaesthesia carts were found. In the Netherlands, there is no uniformity between hospitals in medicines present on anaesthesia carts. There are multiple factors that can influence which medicines are present on an anaesthesia cart. For instance, hospitals with large distances between drug supply stations might benefit from larger stocks of drugs available in the operating room; short distances might give the option to reduce the amount of drugs to a minimum. We agree that guidelines themselves might not improve patient safety. However, we do feel standardising (parts of) medicine drawers might reduce the chance of medication errors. Particularly during emergency settings, in which double checks might be skipped due to time sensitive admission. Furthermore, an increasing number of anaesthesia professionals are working at multiple hospitals. Uniformity in medication drawers might reduce the chance of medication mix-ups for these groups of caregivers. We also realise that customs regarding the practice of anaesthesia might differ between regions/countries. However, we do feel constructing a list containing a minimum set of medicines that should always be present can improve patient safety. Regarding implementation, local anaesthesia professionals should decide which medicines are regarded as mandatory for permanent presence in medicine drawers. After construction of a list of medicines that should always be present, localisation (using colour coding, for instance) of medicines in the drawer should be performed, creating a medicine drawer that is optimally suited for the practice of anaesthesia in the specific region. Acknowledgements relating to this article Assistance with the letter: we would like to acknowledge Marijke Hemels-Kouwen for her assistance in data collection. Financial support and sponsorship: support was provided solely from institutional and departmental sources. Conflict of interests: none.

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