High risk drugs and PACU pitfalls

error high risk pacu recovery Feb 18, 2026

The PACU is a place of transition. Patients are emerging from anaesthesia, physiology is shifting, and vigilance matters. It is also a setting where high risk medications are frequently administered or wearing off. Sedatives, opioids, neuromuscular blocking agents, vasoactive infusions and insulin all carry potential for harm if monitoring and communication are not seamless.

Medication related harm remains a significant contributor to adverse events in acute care. Transitions of care, including transfer from theatre to PACU, are recognised vulnerability points. In recovery, residual anaesthetic effects, altered consciousness and incomplete handover can combine with high risk drugs to create preventable complications.

Residual neuromuscular blockade is one example. Inadequate reversal can lead to airway obstruction, hypoventilation and hypoxaemia after arrival in PACU. Opioid related respiratory depression may be delayed, particularly when long acting agents or multimodal analgesia are used. Insulin and vasoactive drugs require precise titration, as small dosing errors can have rapid haemodynamic consequences.

Key pitfalls to watch for:

  • ๐Ÿ’‰ Incomplete or unclear handover regarding high risk medications given intraoperatively
    • ๐Ÿซ Unrecognised residual neuromuscular blockade or oversedation
    • ๐Ÿ“‰ Inadequate monitoring following opioid or sedative administration
    • ๐Ÿ”„ Failure to reconcile infusions, concentrations or syringe drivers on arrival
    • ๐Ÿงพ Assumptions that a medication has been ceased when it is still active

Practical strategies include structured handover, clear labelling of infusions, objective neuromuscular monitoring, and defined escalation pathways for respiratory depression or haemodynamic instability.

In perianaesthesia nursing, our strength lies in anticipating risk. High risk drugs are part of everyday practice in PACU. Thoughtful assessment, questioning and teamwork are what prevent them from becoming everyday harm.

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References
Institute of Medicine. (2004). Keeping Patients Safe: Transforming the Work Environment of Nurses. National Academies Press.
World Health Organization. (2017). Medication Without Harm: WHO Global Patient Safety Challenge. WHO.
Vaughan, L. et al. (2021). Medication safety in perioperative transitions. BMJ Quality & Safety.
Smith, A.F. et al. (2004). Critical incidents in anaesthesia: An analysis. Anaesthesia.

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