Peri-operative areas are a major location for med errors...and technology is a massive hurdle.
Technology systems such as barcode scanning and automated dispensing cabinets (ADCs) are widely used throughout the hospital...but remain underutilized in perioperative settings.
Plus, other standard safety checks (physician order entry, pharmacist verification, etc) often get bypassed...due to surgeries being time-sensitive and high-stress.
This is especially concerning since many meds administered in operating rooms are high-alert...and can cause harm or even death if given incorrectly.
For example, a patient accidentally received rocuronium...a paralyzing agent...instead of a normal saline flush. The syringe wasn’t properly labeled...and the patient had to be transferred to the ICU.
We know barcode scanning can minimize errors, such as incorrect meds, doses, etc. Look for your hospital to ideally implement barcode scanning in pre-, intra-, and post-op.
Premixed IVs and syringes with manufacturer barcodes should be used whenever possible. Conversely, bar-coded drug labels can be printed off by providers for meds they draw up during the procedure.
Avoid covering barcodes with auxiliary or beyond-use labels.
If peri-op staff alerts you that a product isn’t scanning, loop in your pharmacist ASAP to help make sure it has a functional barcode.
Similarly, remind staff that some premixed IVs come with 2 barcodes...but only one that’ll scan properly. The one that won’t scan may have added info, such as the product’s lot number and expiration date.
Be aware, certain items (fluids, topical fibrin sealants, iodine skin preps, etc) may not require scanning. Use extra caution and double checks when stocking these products so mix-ups don’t occur.
Always scan vials, unit dose tabs, etc, when stocking ADCs or prepping an order.
Additionally, be careful with NON-profiled ADCs. This setting allows routine meds to be removed withOUT pharmacist verification...and increases risk of selecting the wrong patient, med, etc.
Ideally stock any virtual kits for shorter procedures (spinal injections, etc) in profiled ADCs...to require pharmacist verification before dispensing.
Have a plan if ADC mishaps occur. For example, drawers can get jammed due to stuck meds, ADC fridges can malfunction, etc.
- ECRI. Top 10 Health Technology Hazards for 2026 Executive Brief. January 21, 2026. https://home.ecri.org/pages/ismp (Accessed February 4, 2026).
- ISMP. Medication Safety Alert! An Interview: Success with Barcode Scanning to Enhance Perioperative Medication Safety. August 11, 2022. https://www.ismp.org/ (Accessed February 4, 2026).
- ISMP. Guidelines for the Safe Use of Automated Dispensing Cabinets. 2019. https://www.ismp.org/ (Accessed February 10, 2026).
- Patient Safety Network. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. April 27, 2022. https://psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling (Accessed February 4, 2026).