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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. A survey of Canadian anesthesiologists showed that 85% of participants had made at least one medication-related error or close call. Résumé1 Most frequently, these errors involved administering muscle relaxants rather than reversal agents, typically as a result of misidentified ampoules and vials or 'syringe swaps'. Also, survey respondents identified incorrectly stocked medications as one of the contributing factors. Almost two decades earlier, Currie et al. found a similar pattern of results in voluntarily submitted incident reports, and they suggested that erroneously injected medications were frequently administered from a correctly coded or labelled syringe (63% of the time).2 Moreover, these authors noted that one-fifth of ampoule selection errors occurred because the cue to select the 'correct' ampoule was its location. Once selected, the likelihood of detecting the 'incorrect' medication before it was administered was relatively low (42%).Not standardizing the location of medications can contribute to the increased likelihood of an anesthesiologist selecting the incorrect medication or another individual stocking the incorrect medication. Also, inconsistently placing medications contributes to inefficiency, for instance, anesthesiologists and other healthcare providers must spend ti...

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