Controlled Medications in the Operating Theatre: Too Much Work and Too Little Transparency? A sponsor-initiated survey

Background and Importance: 

Opioids and other potent and Controlled Medications are vital therapeutic agents in Acute and Perioperative Care. Management of this group of medications, however, places a responsibility for their physical security, and precise recording of use, of disposal, and of any waste on practitioners and on healthcare facilities. 

Aims and Objectives: 

We wanted to understand more about the burden that the management of controlled substances places on anesthetists and other operating room staff and to know more about issues of supply and availability of these medications. We therefore commissioned the European Society of Anaesthesia and Intensive Care (ESAIC) to conduct a survey within the ESAIC network.  

Methods: 

A panel of five questions were created to review different aspects of Controlled Medication management in the Operating Room. Two ranking exercises were included in the panel: one for a ranking by respondents of the importance of specific factors related to Controlled Medication management, and one for respondents to rank how they would value a selection of proposed interventions that could potentially reduce Controlled Medication errors in the Operating Room. 

Respondents were also asked to estimate how much time was consumed by Controlled Medication management in their daily work.  

The frequency and types of discrepancies to which respondents had been exposed was assessed in the last two questions.   

The survey was piloted to test its suitability for meaningful analysis, and following this assessment a direct email with a link to the survey was sent to ESAIC members in January 2026, with a follow up email link sent in March 2026. Demographic data for the country or region of respondents and their role within the anaesthetic team was also collected during the survey.  

Results: 

A total of 209 responses were received. 18 survey responses were incomplete, 7 of these were missing a response for 1 question. 

From the questions we posed about workload it was evident from the responses that time is being consumed by activities such as searching for Controlled Medications, reordering and returning expired Controlled Medications, and calling or visiting Pharmacy Departments for Controlled Medication refills. When asked to estimate this daily time consumption, the bulk of responses (80.9%) were within a perhaps acceptable range of ‘less than 30 minutes’, but 19.1% of respondents reported these activities consuming between 30 minutes and up to 2 hours of their routine working day.  

Tables 1 and 2 below summarize the responses for documentation and discrepancies, and specific issues around Controlled Medication management. 

Table 1: Issues leading to discrepancies between documentation of medication administration and medication stock usage found during investigations.  

Table 2: Ranking of individual criteria in order of importance related to the use of Controlled Medications (1 = least important, 10 = most important) arranged by Mean Average ranking score.   

With ‘medication safety’ being the most highly ranked criteria perhaps the most valuable information obtained from the survey was from asking respondents to rank specific interventions in terms of their ability to reduce Controlled Medication errors. The most highly scored item with a mean average ranking score of 7.8 (SD: 2.1) was ‘minimizing manual intervention (less paperwork, counting and tracking of Medications)’, followed by ‘integration with a Computerised Provider Order Entry electronic prescribing system’ (Mean: 6.8, SD: 2.4). Having prefilled and barcode labelled Controlled Medication syringes available (Mean: 6.6, SD: 2.7) was seen as less important than the integration and automation of data related to Controlled Medication administration, and this possibly reflects the issue of omission of documentation being seen as a priority problem earlier in the survey. 

Discussion: 

The spread of responses across the sampled territory gave a reasonably random sample as workflows and regulatory frameworks for controlled substance management differ across the continent. This said, there are more than 90,000 anesthetists and nurse anesthetists in Europe (Egger Halbeis et Al, 2008);  

We asked respondents how much time was consumed for Controlled Medication management in their daily routine, of course, it could be suggested that there is no such thing as a routine working day in the Operating Theatre, and Controlled Medications can also consume valuable time when there are discrepancies between the mandated counts of opiates and opioids and the records of their administration. When asked, which of the following have you noted if you have investigated discrepancies between documentation of medication administration and medication stock usage? (Choose all that apply)’, omissions of documentation were the most reported issues. (See Table 1) This is in line with previous work in this area. In a retrospective study of 11,603 elective cases involving the use of narcotics there was a 15% discrepancy rate between dispensed versus administered medications, and ≈ 75% resulted from errors in the amount of drug waste documented. (Vigoda et al, 2007) 

Omissions of medication administration documentation were also noted during an observational study. No documentation was found during this study for 15.1% (n. 90) of instances of drug administration. Omissions occurred mostly during maintenance: 50 of 153 (24.6%), followed by induction: 30 of 325 (9.2%) and emergence: 10 of 57 (17.5%) (P < 0.001). (Avidan, 2014) 

Given the flux of activity in Operating Theatres and increasing pressure driven by a European anesthesia workforce shortage (Pinelli et al, 2025) the above survey results and previous study findings are not surprising. When searching for solutions to the above we need to understand what is important to clinicians.  

In the next section of the survey respondents were asked to rank the importance of individual criteria relating to the use of Controlled Medications in their practice. Increased medication safety scored highest (7.9, SD 2.3) but next in importance was ‘more time for clinical care’ (7.7, SD 2.2), whilst  ‘less Controlled Medication discrepancies was scored at 6.9 (SD 2.2). There is evidence that integration between point of care dispensing systems into pharmacy inventory and supply systems can aid in more rapid flagging up of Controlled Medication discrepancies as well as reducing the risk of ‘stock-outs’ leading to the non-availability of medications at the point of care. In one study there was a 95% reduction in the number of narcotic registry errors after the introduction of an automated and integrated dispensing system (Portelli et Al, 2018). What is perhaps of equal interest to many healthcare professionals, given the growing recognition that many European countries report shortages and overburdened staff in the perioperative care area, posing risks to patient safety, (Buhre et al, 2025) is that the nursing time dedicated to registration activities in the 2018 study was reduced from 36 to 2 hours per month. There may be a lesson to learn here. Finding and retaining perioperative staff, especially anesthetists, is likely to be increasingly challenging. Integrative technologies that can reduce housekeeping tasks, keep up with the clinical and pharmaceutical demands of the Operating Theatre, and assist with ‘push’ functionality to help ensure that any medication administered is documented in both patient and administrative records may help generate staffing time and make the staff we have feel more ‘adequately resourced.’ (Buhre et al, 2025) 

Acknowledgements: 

This article was checked by the Research Committee Chair and Research Committee staff, but was not sent for external peer-review. 

The survey was commissioned by Becton, Dickinson and Company. The survey did not specifically address any product manufactured or distributed by Becton, Dickinson and Company, and was undertaken as a quality -of- care improvement exercise. The survey was created by the Medical Affairs arm division of Becton Dickinson. The Medical Affairs department operates as a distinct arm outside of the commercial operations of the company. 

References 

1. Avidan A, Dotan K, Weissman C, Cohen MJ, Levin PD. (2014) Accuracy of manual entry of drug administration data into an anesthesia information management system. Can J Anaesth. 2014 Nov;61(11):979-85.  
2. Buhre, Wolfgang; Struys, Michel; Klimek, Markus; de Robertis, Edoardo; Ringvold, Else-Marie; Camilleri, Anne Marie; Weynants, Cathy; Matot, Idit. Building resilience in perioperative medicine: ensuring safe care for all: A white paper from the European society of anaesthesiology and intensive care (ESAIC). European Journal of Anaesthesiology ():10.1097/EJA.0000000000002433, June 04, 2026. | DOI: 10.1097/EJA.0000000000002433  
3. Egger Halbeis CB, Cvachovec K, Scherpereel P, Mellin-Olsen J, Drobnik L, Sondore A. Anaesthesia workforce in Europe. Eur J Anaesthesiol. 2007 Dec;24(12):991-1007. doi: 10.1017/S0265021507000762. Epub 2007 Jul 3. PMID: 17608964. 
4. Pinelli F, Romagnoli S, Singh S, Albaladejo P, Nau C and Bilotta F (2025) Anaesthesia practice in Europe: A survey of the National Anaesthesiologists Societies Committee of the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 42:189-202. 
5. Portelli G, Canobbio M, Bitoni R, Della Costanza C, Langella R, Ladisa V. (2018) The Impact of an Automated Dispensing System for Supplying Narcotics in a Surgical Unit: The Experience of the National Cancer Institute Foundation of Milan. Hosp Pharm. 2018;54(5):335-342 
6. Vigoda MM, Gencorelli FJ, Lubarsky DA. (2007) Discrepancies in medication entries between anesthetic and pharmacy records using electronic databases. Anesth Analg. 2007 Oct;105(4):1061-5. 

Authors

• Dipak Duggal
• Samuel Garcia
• Stefan Schraag  
• James Waterson