Perioperative medication administration is more prone to error than other settings where medication is administered, such as hospital wards, outpatient clinics and the critical care unit, because of its uniquely high-stress, high-stakes environment, which moves at a faster pace and may involve bypassing standard safety checks that exist elsewhere in the hospital. Despite limitations, the best available data indicate that drug errors are not rare, inconsequential events caused by distracted or inexperienced care providers. The results suggest that the first step to reduce errors is to heighten awareness and revise education curriculum regarding drug safety in the operating room .

Education is essential but not sufficient to reduce drug errors, as the problem of anesthesia medication safety has been recognized for years. For example, an analysis of closed medical–legal claims against…