Abstract

Background: Medication errors remain a significant patient safety concern in anesthesia practice, particularly those involving look-alike medications and similar vial packaging. This case describes a near-miss event during routine pre-induction medication preparation in which a certified registered nurse anesthetist (CRNA) mistakenly selected a vial of methocarbamol instead of lidocaine due to identical cap color, vial size, and storage conditions. Although the error was identified before administration and no patient harm occurred, the incident revealed critical system vulnerabilities inherent in anesthesia medication workflows.

Clinical Question: In adult patients undergoing elective surgery with general anesthesia, does the use of mandatory syringe labeling and double-check verification protocols, including barcode scanning, compared with a self-checking system, reduce look-alike medication administration errors by at least 50% throughout the perioperative period?

Evidence-Based Discussion: The literature demonstrates that perioperative medication errors occur in approximately 5% of drug administrations, with nearly 80% considered preventable. Look-alike vial confusion contributes substantially to these events. Reliance on self-checking alone is limited by human cognitive biases, including confirmation and expectation bias. Evidence consistently shows that structured redundancy—such as mandatory double-checks, standardized labeling, and barcode verification—significantly reduces wrong-drug errors. Barcode scanning has been shown to intercept up to 70% of wrong-drug administrations, and when combined with standardized labeling and verification protocols, overall error reduction exceeds 50%. Human factors research supports system redesign over reliance on individual vigilance.

Translation to Practice: Effective translation requires both provider-level and system-level interventions. Mandatory syringe labeling, structured double-checks, barcode scanning, improved storage separation, auxiliary warning labels, and a nonpunitive reporting culture collectively provide the most effective protection against look-alike medication errors. This case reinforces that layered, system-based safety strategies are essential to reducing preventable anesthesia medication errors and improving patient safety outcomes.

Author Details

Harrison B. Hansard, DNP(c), BSN; Lauren Barnes, DNP, CRNA

Sigma Membership

Non-member

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Case Study/Series

Research Approach

Translational Research/Evidence-based Practice

Keywords:

Medication Errors, Drug Administration, Anesthetics, Medication Errors -- Prevention and Control, Drug Storage, Look-Alike Medications, Anesthesia Safety

Advisor

Lauren Barnes

Second Advisor

Terri M. Cahoon

Degree

DNP

Degree Grantor

Samford University

Degree Year

2026

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Proxy-submission

Date of Issue

2026-03-19

Full Text of Presentation

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Additional Files

Abstract.pdf (90 kB)

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