Standardizing anesthesia medication drawers using human factors and quality assurance methods

Can J Anaesth. 2010 May;57(5):490-9. doi: 10.1007/s12630-010-9274-8. Epub 2010 Feb 9.


Purpose: In Calgary, each of the three acute-care adult hospitals had different anesthetic medication carts with their own type and layout of anesthetic medications. A number of anesthesiologists moved among the different sites, increasing the potential for medication errors. The objective of this study was to identify the anesthetic medications to include and to determine how they should be grouped and positioned in a standardized anesthesia medication cart drawer.

Methods: A standardized list of medications was established. Next, the anesthesia medication cart drawer was filled and photographed, and a jigsaw puzzle was made from the photograph. Anesthesiologists and anesthesia assistants arranged the jigsaw pieces into an ideal drawer. Participants verbalized their rationale for the position of each puzzle piece. Results were collated and analyzed. A mock drawer was developed and reviewed by department members, and minor modifications were made.

Results: A final standardized medication drawer (content and positioning) was developed over 30 months, with agreement from anesthesiologists (n = 12) and anesthesia assistants (n = 3) at the three hospitals. Guidelines for placing each medication in the drawer included grouping them according to order of use, frequency of use, similarity of action, severity of harm from misuse, and lack of similar appearance. A finalized template was used for a standardized drawer and installed in every operating room of the three hospitals.

Conclusion: Implementation of the standardized medication drawer is expected to reduce the likelihood of medication errors. Future research should include testing the clinical implications of this standardization and applying the methodology to other areas.

MeSH terms

  • Adult
  • Alberta
  • Anesthesiology / organization & administration
  • Anesthetics / administration & dosage*
  • Guidelines as Topic
  • Humans
  • Medication Errors / prevention & control*
  • Medication Systems, Hospital / organization & administration
  • Medication Systems, Hospital / standards*
  • Operating Rooms / organization & administration
  • Quality Assurance, Health Care / methods


  • Anesthetics