Medication safety is a well-established priority across healthcare. Barcode scanning, smart infusion pumps, and automated dispensing cabinets are now standard safeguards in many inpatient areas. Yet in one of the most complex and high-risk environments in the hospital—the operating room—perioperative medication safety continues to lag.
According to ECRI’s Top 10 Health Technology Hazards for 2026, perioperative settings remain vulnerable due to the underutilization of medication safety technologies in the OR. This is not a hypothetical concern. It reflects the reality of operating room workflows, where high-alert medications are administered quickly, often by a single provider, under intense time pressure and without a second safety check.
Why Medication Safety in the OR Is Different
Perioperative care differs fundamentally from other clinical environments, and those differences matter for medication safety. In anesthesia and surgical workflows, medications are frequently ordered, prepared, administered, and documented by the same clinician. Documentation often happens after the fact, once the immediate clinical priorities are under control. Interruptions are common, and patient conditions can change rapidly.
In the middle of a case, an anesthesia provider may be managing the airway, monitoring hemodynamics, communicating with the surgical team, and responding to sudden changes—all while administering medications. It is a high-focus, high-stakes environment where the margin for distraction is small.
ECRI highlights that medications routinely used during surgery, such as opioids, anesthetics, and vasopressors, are considered high-alert medications. Errors in dosing, timing, or selection can result in serious patient harm. Yet the medication safety technologies widely adopted on nursing units are not consistently embedded into operating room medication management.
The result is a gap driven not by lack of awareness, but by workflow complexity and limited visibility.
If the Technology Exists, Why Does the Gap Persist?
The challenge is not simply deploying more technology; it is integrating medication safety tools into perioperative workflows that reflect how care is actually delivered in the OR.
Many medication safety systems were initially designed for inpatient nursing environments, where workflows are more linear, and medication administration often includes multiple verification steps. When those same tools are applied to perioperative settings without adaptation, they can feel disruptive or impractical. Clinicians may bypass safeguards—not out of carelessness, but because the tools do not align with the pace and flow of surgical care.
ECRI points to cost concerns, training limitations, and workflow misalignment as contributors. But the underlying issue is often a lack of real-time visibility. Without a clear, reliable view of what medications are administered, when they are given, and how they are documented, safety depends too heavily on human recall in high-stress moments.
That reliance does not just affect patient safety. It also impacts quality reporting, compliance, and the ability of organizations to analyze perioperative performance with confidence.
Closing the Gap Starts with Visibility and Workflow Alignment
Improving perioperative medication safety does not require reinventing surgical care. It needs improving visibility, consistency, and reliability in anesthesia medication management—without adding unnecessary burden to clinicians already managing complex situations.
This is where perioperative-focused clinical information systems can make a meaningful difference. Solutions such as Picis Anesthesia Manager are explicitly designed around anesthesia and operating room workflows. By capturing medication administration data as part of the natural flow of care, rather than as an afterthought, these systems help reduce reliance on retrospective charting and manual memory.
When medication information is captured accurately at the point of care, organizations gain clearer insight into perioperative workflows, improved compliance with safety protocols, and more reliable data for quality improvement and reporting. Just as importantly, clinicians are supported during critical moments rather than slowed down by technology that does not reflect their reality.
From Medication Safety Technology to Safer Practice
ECRI’s findings reinforce a critical takeaway: medication safety in perioperative settings is not just about having the right tools; it is about implementing them in ways that support real clinical practice.
For perioperative leaders, closing the gap means evaluating how medications move through the OR, identifying where visibility breaks down, and ensuring technology aligns with clinical workflows. It means recognizing that the operating room is not simply another inpatient unit, but a distinct environment that requires solutions designed for its unique pressures.
The operating room will always be complex. But with better visibility, thoughtfully implemented medication safety technology, and systems built specifically for perioperative care, it does not have to remain a high-risk blind spot.
Frequently Asked Questions About Medication Safety in the OR
What is perioperative medication safety?
Perioperative medication safety focuses on ensuring medications are accurately administered and documented before, during, and after surgery.
Why are operating rooms high-risk environments for medication errors?
Operating rooms involve high-alert medications, rapidly changing patient conditions, and fast-paced workflows that increase the risk of medication-related errors.
What are high-alert medications?
High-alert medications are drugs that can cause significant patient harm if administered incorrectly. Examples include opioids, anesthetics, vasopressors, and neuromuscular blocking agents.
How can hospitals improve medication safety in anesthesia workflows?
Hospitals can improve medication safety by implementing workflow-aligned clinical information systems, improving visibility into medication administration, reducing manual documentation, and supporting clinicians at the point of care.
What role does anesthesia documentation play in medication safety?
Accurate anesthesia documentation improves visibility into medication administration, supports compliance initiatives, and provides more reliable data for quality improvement programs.
Source & Credit
This article is informed by ECRI’s Top 10 Health Technology Hazards for 2026 – Executive Brief, specifically Hazard #6: Underutilizing Medication Safety Technologies in Perioperative Settings. ECRI is an independent, nonprofit organization dedicated to improving healthcare safety, quality, and cost-effectiveness.
About the Author
Shari Medina, MD, serves as Medical Director at Harris Computer, where she applies her extensive background in medicine and health IT to advance safe, effective care delivery.