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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Implementation of a Basic Drug Tray Organization System to Decrease Medication Errors: A Global Health Initiative

Abstract Number: F1A-6
Abstract Type: Original Research

Benjamin R Johnson MD1 ; Milly Turakhia MD2; Christopher Schilf MD3; Joseph Bavaro MD4; Feyce Peralta MD5; Juan Andres Henriquez MD6

Background: Medication error is the third-leading cause of inpatient deaths in the United States (1). The operating room is particularly conducive to these errors, in part due to a single anesthesia provider selecting, preparing, and administering medications during surgery. Studies show over 85% of anesthesiologists report making a medication error during their career (2,3).

During a global health initiative at a large maternity hospital in the Dominican Republic in January 2018, we observed unorganized anesthesia medication bins without discrete compartments containing brown or clear glass ampules of roughly the same size and appearance. We also observed several medication error near-misses. We hypothesized that the majority of anesthesia providers would support a basic medication organization system as a way to decrease drug errors and expedite drug administration.

Methods: After institutional approval at this maternity hospital in the Dominican Republic we conducted a survey to gauge attitudes of staff anesthesiologists towards medication errors and willingness to adopt a system of medication organization. We designed and implemented a standardized reusable medication tray with discrete compartments and color-coded labels. Then, after a one-week period, we conducted a post-implementation survey to evaluate utility of these trays.

Results: A pre-implementation survey revealed 90% of anesthesiologists thought a new medication system would benefit patient care, and a post-implementation survey showed 100% of anesthesiologists favored continued use of this system (Figure).

Conclusion: Decreasing medication error related morbidity requires a sustainable system for identifying errors and decreasing frequency of errors (1). Utilizing a standardized labeled and organized drug tray improved the preexisting system at this maternity hospital by facilitating correct medication identification and administration, which will likely reduce drug administration errors from look-alike vials. Importantly, anesthesiologists supported this new system, increasing the likelihood of its long-term adoption.


1. Makary MA, and Daniel M. BMJ 353 (2016).

2. Merry AF, Webster CS, and Mathew DJ. Anest Analg 93.2 (2001): 385-390.

3. Orser BA, Chen RJB, Yee DA. Can J Anaesth 48.2 (2001): 139.

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