Anesthesia Patient Safety Podcast

#289 Forty Years Of Anesthesia Medication Safety: What Works And What’s Next

• Anesthesia Patient Safety Foundation • Episode 289

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A single syringe swap should never decide a patient’s fate. We pull back the curtain on forty years of anesthesia medication safety to show what truly works—then tackle the hard part: getting proven safeguards into every OR, every time. From look-alike vial hazards to standardization that actually sticks, this conversation blends frontline realities with practical steps leaders can implement now.

We dig into the high-stakes TXA wrong-drug, wrong-route crisis and explain why eliminating vials and moving to ready-to-administer IV bags is a must. Along the way, we unpack new FDA label warnings, the APSF–ISMP joint recommendations, and the forcing functions that prevent catastrophes, including NRFit for neuraxial routes and barcode verification at the point of care. We also surface quieter threats—vial coring, variable concentrations, and chaotic storages—and show how color-coded, readable labels and organized carts reduce cognitive load when seconds matter.

Opioid safety gets equal focus. We connect preoperative risk assessment, multimodal analgesia, and smart postoperative monitoring to reduce opioid-related harm without compromising comfort. Technology has matured too: AI-driven clinical decision support can flag dosing and drug-choice risks in real time, but only if woven into workflows that clinicians trust. Throughout, we return to the implementation gap: success depends on leadership support, supply chain alignment, failure mode analysis, transparent reporting, and peer support that sustains a just culture.

If you care about safer anesthesia—standardized labels and concentrations, prefilled syringes, organized storage, barcode checks, and a culture that learns—this is your playbook. Listen, share with your team, and help push your institution from knowing to doing. Subscribe, leave a review, and tell us which safeguard you’ll champion next.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/289-forty-years-of-anesthesia-medication-safety-what-works-and-whats-next/

© 2026, The Anesthesia Patient Safety Foundation

SPEAKER_01:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We are still celebrating the new year here on the podcast with the exciting conclusion to our two-part series on medication safety that we started last week. Last week, we talked about the history of the APSF's work to improve medication safety during anesthesia care. There is still more work to be done, so let's keep the conversation going. Before we dive further into the episode today, we'd like to recognize Vertex, a major corporate supporter of APSF. Vertex has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Vertex. We wouldn't be able to do all that we do without you. Our featured article once again today is APSF's 40-year commitment to medication safety in anesthesia by Aubrey Simost Williams and colleagues. To follow along with us, head over to APSF.org and click on the newsletter heading. The first one down is the current issue. From there, scroll down to our featured article today. And I will include a link in the show notes as well. Medication safety is one of the APSF's patient safety priorities, and it has been a priority since the APSF was founded in 1985. Last week we talked about the challenge of medication safety in the operating room, since it may just be the sole anesthesia professional who is responsible for selecting the medication and dose, preparing the medication, and administering the medication. This is a unique challenge for anesthesia professionals. Other places in the hospital have three different groups of people performing these tasks, and this adds in a couple of layers of safety checks. We also talked about recommendations from the 2010 and 2018 APSF Stolting Conferences on medication safety as well as APSF Medication Safety Initiatives. Now it's time to get back into the article. Let's check out the work that the APSF has done between 2018 and the 2024 APSF Stolting Conference. There are some exciting initiatives that you may be familiar with because we have talked about them before on the podcast. First up, the Lookalike Drug Vials Gallery was created in 2018. This resource has helped the APSF develop further industry partnerships to address the challenge of look-alike vials. We hope that you will check it out. Head over to apsf.org and click on the patient safety resources heading. The first one down is initiatives, and then the first drop down is the look-alike drug vials gallery. I will include the link in the show notes as well. The alerts and photos in the gallery show how look-alike drug vials and packaging can contribute to medication errors and impact patient safety. The latest alert is from December 22nd, 2025, and includes pictures of multiple different appearing versions of commonly used drugs in an anesthesia drug cabinet, including on Dancetron, Metaclopromide, and Dexamethasone. We hope that you will check out the gallery and consider submitting a look-alike drug alert the next time you have come across look-alike medications in your anesthesia practice. Next, we have the APSF Patient Safety Advisory Groups, which were formed in 2021 and includes a medication safety group. Members of this group include anesthesiologists, certified registered nurse anesthetists, anesthesiologist assistants, anesthesiology residents, pharmacists, perioperative nurses, a lawyer specializing in medical malpractice, and industry partners representing pharmaceutical and device companies. The group is working on implementing recommendations from the 2024 Stolting Conference. Important work has been done by the APSF on medication errors involving intra-tecal administration of tranhexamic acid, or TXA. You can check out the June 2024 APSF newsletter article, Unraveling a Recurrent Wrong Drug, Wrong Route Error, Tranexamic Acid in Place of Bupivacaine, a multi-stakeholder approach to addressing this important patient safety issue. Or listen to episode number 209 of this podcast for more information about this serious medication error. By working with industry partners, the APSF has promoted the availability of TXA in infusion bags and reduced the use of TXA in vials in the perioperative environment. Has your hospital made the switch to infusion bags of TXA? If not, have you removed TXA vials from the operating rooms? These changes can make a big difference for improving medication safety. More work was done by the APSF in 2024, together with the Institute for Safe Medication Practices, the ISMP, to investigate reports of coring of vial tops when preparing medications for administration. Check out the March 2025 Alert for anesthesia professionals in the United States, patient safety alert, urgent alert regarding medication vial coring and fragmentation risks. And I will include a link in the show notes as well. One more example involves the advocacy of the APSF for the reinstatement of the American Society for Testing and Material Standard D4774, which standardizes the color coding used on labels for different medication classes. This is important work by the APSF for these industry-wide standards to make sure that concerns from practicing anesthesia professionals are incorporated into the equipment that we work with every day in the operating room. And now it's time to talk about the most recent APSF Stolteing Conference on medication errors and opioid safety from 2024. This time there was an additional focus on the harms of opioids in the immediate postoperative period and beyond, and considerations for multimodal pain management, and the role for safe opioid use. Technology has also come a long way with the rise of artificial intelligence, and this may make a big difference for preventing medication errors in the future with clinical decision support tools that can help determine whether the medication to be administered is a good choice given the patient's current physiological state. There are also new challenges and safety risks that we need to consider. This conference also highlighted the many of the medication safety challenges have not changed in the past 40 years. We are still seeing basic syringe swaps and medication dosing errors due to differing concentrations. The two earlier Stoltin conferences recommended work on human factors and system safety principles. We now know how important it is to improve these processes and identify best practices for medication safety, but there is a big gap when it comes to implementation. You are probably aware of this gap in your own anesthesia practice. In a pre-conference poll prior to the 2024 Stolten Conference, attendees reported that fewer than half of their institutions had fully implemented practices such as standardized drug labeling, pre-filled syringes for at least three unique medications, or standardized medication drawers for automated dispense cabinets or medication trays. And this is from a group that was self-selected for interest and leadership in medication safety. Going forward, we would like to see top standardization strategies that include syringe label design, color-coded syringe labels, standardized concentrations, pre-filled syringes, and standardized medication storage locations during surgery. Another goal is to help prevent opioid-related harm and must include appropriate preoperative assessments, postoperative monitoring, and research into non-opioid alternatives. We know what we need to do to improve medication safety. The next step is to pivot to implementation science to better identify barriers and help institutions be successful to implement measures that we know can save lives. We have come a long way over the past 40 years when it comes to medication administration, and we are excited where the next 40 years will take us. Our crystal ball reveals that we will need to incorporate human factors, cutting-edge technology, systems engineering, and implementation science together with increased collaboration between pharmacists, nurses, institutional leadership, industry, safety organizations, standard setting organizations, and federal agencies. Before we wrap up for today, we are going to hear from Elizabeth again. I also asked her what she envisions for the future when it comes to medication safety. Here is her response.

SPEAKER_00:

Implementation science is the next leap. We know what works. Standardized concentrations and labeling, pre-filled syringes, organized storage, barcode-based identification, and robust documentation. Yet, adoption still lags. The future is closing that gap reliably across institutions. Add to that smarter clinical decision support, continuous learning from near misses, and stronger partnerships with industry and the FDA. Safer systems everywhere will provide a promising future.

SPEAKER_01:

Elizabeth also shared what she hopes to see going forward. Let's take a listen now.

SPEAKER_00:

I hope to see universal basics, color-coded readable syringe labels, standardized drug carts and ADC drawers, elimination of concentrated agents in the OR, and routine pharmacy-prepared or pre-filled syringes. I'd like to also open reporting cultures. When these elements are in place, the workload shifts, freeing the anesthesia professional to focus on the patient in front of them.

SPEAKER_01:

Thank you so much to Elizabeth for contributing to our show today and for your work on medication safety. We are looking forward to a future with implementation of these medication safety recommendations so that we can focus on the patient in front of us. And speaking of medication safety, have you seen the recent announcement from the APSF and the ISMP? Preventing wrong drug, wrong route errors involving tranxamic acid and local anesthetics? This was published online in November 2025. To follow along, head over to APSF.org and click on the Patient Safety Resources heading. The fifth one down is news and updates, and then scroll down until you see our next featured article. We have talked about this dangerous wrong drug, wrong route medication error where intravenous tranexamic acid has been inadvertently administered into the intrathecal space in place of local anesthetics, such as bupivacaine and ropivacaine. The mortality following these events may be 50%, with survivors often left with permanent neurological harm. The FDA has recently increased awareness about this potentially fatal patient safety threat by issuing the following changes to the trannexamic acid prescribing information. Added a boxed warning to communicate the risk of medication errors involving inadvertent neuroaxial administration of tranexamic acid injection. Added a statement to indicate that trannexamic acid injection is contraindicated as a neuraxial injection. And updated the dosage and administration section to clarify that tranexamic acid injection is only to be administered intravenously and to provide instructions for preparing and administering the diluted solution. The FDA also recommends that the container labels for trannexamic acid injection prominently display the product name and IV route of administration. I will include a link to the FDA information in the show notes. When it comes to this medication error, let's review the key safety concerns. Tranexamic acid and local anesthetics are frequently stocked in similar packaging, files or ampules, and similar storage locations, creating a high risk for look-alike drug mixups. Both of these medications are commonly used during the same types of surgery, with the majority of catastrophic wrong drug, wrong route errors occurring during orthopedic, arthroplasty, and other procedures. These drugs are often stocked in areas where barcode scanning is not routinely used, such as the perioperative areas, labor and delivery, or the emergency department. Thus, mix-ups are less likely to be detected. Intrafecal administration of tranexamic acid is a never event that causes seizures, paraplegia, cardiovascular collapse, and death. Traditional safeguards such as education and double checks are not sufficient on their own. Higher level system strategies and safeguards must be adopted. We hope that everyone listening assumes that this may be a risk within your organization. Don't wait until you have an event to take action. And here are the joint recommendations from the APSF and ISMP so that you can take action right now to keep patients safe and prevent tranhexamic acid and local anesthetic mixups. Number one, removal of tranhexamic acid vials and ampules from the perioperative areas. Only ready to administer tranhexamic acid pre-mixed IV bags, 1000 mg from manufacturers, compounding pharmacies, or institutional pharmacies should be stocked and available in the perioperative environment. Healthcare organizations should meet with key stakeholders to review their workflow when ordering and administering trannexamic acid injection, to understand usage, seek agreement with stakeholders to eliminate the availability of multiple concentrations, and work towards a standard concentration. Some off-label uses may occur in specific circumstances that require a vial, such as preparing soaked gauze. In these cases, appropriate alternative safety measures should be identified and implemented. When the 100 milligram per ml tranexamic acid injection vial or ampule is being used in an off-label manner, consider completing a failure mode and effects analysis to identify potential failure modes and mitigation strategies such as restricting access. The second recommendation is implementation of high-leverage system safeguards. Use barcode scanning or other technology-assisted machine readable code at the point of care for verification before administration. Employ forcing functions and fail-safes, such as the NRFIT connectors, for use with medications appropriate for neuraxial administration in order to prevent wrong route delivery of medications. And standardize workflows to minimize the need for practitioner-prepared syringes. The third recommendation involves institutional and regulatory support. Hospital and health system leaders must support medication safety by prioritizing the elimination of unsafe drug presentations and ensuring access to commercially available pre-mixed infusion bags or standardized pharmacy-prepared alternatives. Regulatory agencies, accrediting bodies, and manufacturers should align to require safer packaging and distribution practices for trannexamic acid. And finally, the fourth recommendation involves fostering a culture of safety. Gather feedback from practitioners and establish non-punitive reporting systems for near-miss and error events. Report incidents internally to the FDA, MedWatch, and ISMP. Provide peer support for practitioners involved in adverse events. And regularly review system vulnerabilities and medication safety data with key stakeholders. Tranexamic acid is an effective medication that improves outcomes in surgical and obstetric patients when used correctly. The risk is unacceptably high for a catastrophic wrong drug, wrong route error when tranhexamic acid in vials and ampules remains available in the perioperative setting. So what are you waiting for? The time to act is now to eliminate tranxamic acid vials and ampules from the perioperative environment and transition to ready-to-administer products supported by robust system safeguards. If you have any questions or comments from today's show, please email us at podcast atapsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.