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Injectable medicines in theatres | Signal

Reference number
1162 C
Issue date26 February 2010

This Signal relates to risks of preparing and administering injectable medicines in theatres, including unlabelled solutions in open containers.


The preparation of injectable medicines is a highly complex process, involving many steps where errors can happen. Problems in preparing and administering injectable medicines account for 62 per cent of all medication safety incidents reported to the National Reporting and Learning Service (NRLS) as leading to death or severe harm (Safety in Doses, 2009).


In 2007, NRLS issued a Patient Safety Alert to improve the safety of injectable medicines. This is general guidance, but NRLS has also been made aware of particular risks in the in the surgical setting. These include:

  • the range of staff involved (e.g. radiologists, physiologists and perfusionists as well as surgical and anaesthetic teams)
  • lack of standard operating procedures for common practices (e.g. flushing lines, inflating balloons, bathing wires in heparinised saline)
  • problems posed by ‘sterile field issues’ (e.g. sterile labels supplied but no sterile pen to record strength on label)
  • medicines prepared by one staff and given by another.


A typical incident report reads:
"Patient undergoing cataract surgery had the drug cefuroxime injected into the anterior chamber of the eye instead of balanced salt solution. The patient sight although slightly improved post operation is believed to have been permanently harmed."


Incidents in the database indicate problems relating to the preparation and administration of injectable medicines in the operating theatre. These include issues such as:

  • solutions being made-up outside the pharmacy and stored in unlabelled gallipots, which increases risk of confusion
  • `look-alike’ syringes on scrub nurses’ trolleys
  • problems with infection control (hence the need for sterile labels).

This issue was discussed at the Clinical Board for Surgical Safety in January 2010, where it was agreed that there may be low awareness of risks in this setting. Responses to the problem include ending the practice of storing solutions in open containers and considering the need for pre-filled syringes (prepared in the pharmacy) where appropriate. Training resources are available which may be useful for scrub nurses, operating department practitioners and others.


Have you encouraged theatre staff to report incidents?

Do you have any good practice to share (for example, some trusts have identified a dedicated member of the pharmacy team to liaise with theatres)?


Relevant to: Medication safety, surgery




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