THIS WEEK'S ARTICLES
Medication Errors in the OR - Sponsored Content
Will the Vaught Verdict Make Surgery Less Safe?
Experts fear the prospect of criminal charges for medical mistakes will limit self-reporting and exacerbate an ongoing staffing crisis.
With the danger of criminal prosecution hanging over their heads, how many frontline nurses — many of whom are already burnt out from the harrowing experiences of the pandemic — will risk coming forward to self-report their mistakes in a post-Vaught healthcare landscape? That's one of the big questions healthcare professionals everywhere are asking in the wake of the recent RaDonda Vaught ruling.
While working as a nurse at Vanderbilt University Medical Center (VUMC) in Nashville on Dec. 26, 2017, Ms. Vaught accidentally administered the neuromuscular blocker vecuronium instead of the prescribed sedative Versed (midazolam) to 75-year-old brain injury patient Charlene Murphey before Murphey went into an MRI machine. Ms. Murphey died a day after the medication error, and Ms. Vaught was eventually fired on Jan. 3, 2018, reportedly for not following the "five rights" of medication administration.
The Tennessee District Attorney's Office then took the unusual step of pursuing criminal charges, which led to a landmark court case and guilty verdicts of criminally negligent homicide and gross neglect of an impaired adult. On May 13, Ms. Vaught was sentenced to three years of supervised probation.
Healthcare professionals everywhere are concerned about the fallout from the verdict. One of the most vocal critics of the ruling has been the Institute for Safe Medication Practices (ISMP), a nonprofit group that provides programs, tools and guidelines designed to prevent medication errors. It believes mistakes made by healthcare workers should not be criminalized.
ISMP President Emeritus Michael Cohen, RPh, MS, FASHP, says the criminalization of medication errors could directly impact patient safety by making providers less likely to be transparent and report future mistakes. "When RaDonda Vaught was convicted, the entire healthcare community lost as well," he says. "Her conviction, which made a scapegoat of one individual instead of focusing on fixing larger, preventable systemic issues, will have serious consequences for patient safety."
Those consequences, says Mr. Cohen, could range from a lack of self-reporting, which is critical for the prevention of future errors by helping staff learn from the mistakes of others, to recruiting issues for an industry already plagued by staffing shortages. "If nurses believe that society, their community and the judicial system holds them to a standard of perfection, why would they want to work in health care?" asks Mr. Cohen.
Mr. Cohen's dire predictions are shared by Robyn Begley, DNP, RN, chief nursing officer of the American Hospital Association and CEO of the American Organization for Nursing Leadership. "We must encourage nurses and physicians to report errors so we can identify strategies to make sure they don't happen again," she says. "Criminal prosecutions for unintentional acts are the wrong approach. They discourage health caregivers from coming forward with their mistakes and will complicate efforts to retain and recruit more people into nursing and other healthcare professions that are already understaffed and strained by years of caring for patients during the pandemic."
The Most Common Medication Mistakes Are Avoidable
Safety group offers solutions on how to avert potentially dangerous errors.
Half of the errors reported to the Institute for Safe Medication Practices (ISMP) could cause serious harm to patients in outpatient perioperative settings, says ISMP President Emeritus Michael Cohen, RPh, MS, FASHP. Here are his recommendations on how to address these frequently reported errors.
Inappropriate opioid prescriptions. ISMP continues to receive reports of opioid-naïve patients receiving extended-release opioids, mostly after visits to ERs, but the problem applies to post-op patients as well. ISMP recommends accessing patients' records to look for past opioid use; using extra caution when prescribing to those who aren't familiar with opioids; and not prescribing opioids based on informal patient information such as a belief that they're "allergic" to codeine. "Always strive for the lowest dosages and frequencies when opioids are appropriate," says Mr. Cohen.
Misuse of infusion pumps. ISMP recommends using smart infusion pumps with dose-error reduction systems (DERS) that alert providers of incorrect medication orders or calculation errors that could result in the wrong amount of drug or fluid being administered. Use of DERS in perioperative settings is limited, however, with many ORs operating smart pumps on "anesthesia mode" while failing to understand that this default setting reduces hard stops to soft ones, which can result in dangerous overrides of dosing and concentration limits that should never be bypassed.
"A range of hard limits for medication doses should be implemented, and putting the pumps on ‘anesthesia mode' shouldn't be allowed if it restricts the ability to individualize a patient's infusion limit," says Mr. Cohen. "Anesthesia providers should be required to use a bolus setting with hard limits for catastrophic doses whenever the feature is available."
Wrong-route tranexamic acid injections. This potentially fatal error often occurs when staff confuses tranexamic acid, which is used to control bleeding during surgeries, with local anesthetics bupivacaine and ropivacaine, simply because all three medications can come packaged with caps that are the same shade of blue. "ISMP strongly urges storing tranexamic acid in a different location than look-alike vials, adding a label that highlights that it is intended for IV-only administration, and purchasing connectors for local anesthetics that are designed to prevent misconnections with drugs intended for IV use," says Mr. Cohen.
Medication mix-ups. More attention and awareness are needed surrounding look-alike and sound-alike (LASA) medications. Many such mistakes occur due to similar vial sizes and identical cap colors when selecting vials from "cap up" storage methods. To avoid these issues, organize medication storage areas to avoid the proximity of LASA vials and ampules. Ideally, when setting up storage in anesthesia workstations, automated dispensing cabinets or anesthesia carts, the labels of vials or ampules should be readily visible to the provider, not just the caps. Consider employing barcode scanning or other machine-readable coding to assist with drug identification prior to preparation and administration, adds Mr. Cohen.
Shorthand shortcuts. Drug abbreviations, symbols and dose designations can save time, but also can be misread and misinterpreted. When providers shorten a word or phrase to fit it into a small box on a form or abbreviate names of multi-syllabic drugs to avoid misspellings, inadvertent patient harm can result. The biggest errors surrounding shortcuts are associated with doses and measurement units, routes of administration and drug names. ISMP warns to never use abbreviations in verbal, electronic or handwritten communications.
"It's vital to always keep medication safety top of mind and strive to improve how drugs are stored, tracked and administered," says Mr. Cohen. "Proper medication management, as always, remains an essential component of safe patient care. All these potentially serious medication errors can be avoided through better safety practices and system changes."
Medication Errors in the OR
Help prevent costly errors and minimize risk with the color-coded flag system.
In a fast-paced, complex environment riddled with distractions and interruptions, the operating room remains a high-risk environment for medication errors. Responsible for delivering technically complex care, the perioperative team now faces increased risk for human error due to the additional challenges of staffing shortages, fatigue and ongoing stress.
Medication errors occur as often as 1 out of every 20 medication administrations, with nearly one-third contributing to patient harm.1 Comprehensive studies have identified the primary causes leading to these errors, which include distraction, miscommunication, fatigue and haste.
Additional environmental factors have been shown to contribute to medication errors, including increased workload and prolonged procedures with more than 20 medication administrations.2 These factors can lead to labeling errors, which result in incorrect medication administration, adverse reactions and patient harm — all of which are preventable.
The necessity of enhanced labeling
The Joint Commission's 2022 National Patient Safety Goals (NPSG) require all unlabeled medications to be labeled before a procedure begins. This includes medications in syringes, cups, and basins.3 During the complex process of administering medication in the perioperative environment, it's standard to remove medications from original containers with syringes, then place them on the sterile field.
During this preparation, proper labeling becomes critical in preventing patient harm. One study showed that almost 70 percent of medication errors in the perioperative setting occurred during preparation.4 Handwritten labels with similar looking and sounding medications can be difficult to read. Without enhanced labeling solutions in place, these scenarios can lead to devastating errors.
Over the years, because of continued education, leadership and recommendations from the Joint Commission and AORN, many facilities have moved toward more effective labeling systems designed to minimize risk for patients and avoid costly errors.
Ansell offers a comprehensive medication labeling system designed to reduce the risk of medication errors in the operating room. In addition to moisture-proof, pre-printed labels, the SANDEL® Correct Medication Labeling System™ has a patented color-coded flag system designed to maximize label visibility and match the medication container to the corresponding syringe. Medication labeling kits can also include a variety of skin and permanent markers as well as a specimen zone to help organize and label specimens on the sterile field. The system meets AORN recommendations and complies with Joint Commission's NPSG requirements.
Note: To request a sample, please visit Ansell.com/SANDEL
1. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and ad-verse drug events. Anesthesiology. 2016;124(1):25-34
2. Factors Contributing to Perioperative Medication Errors: A systematic Literature Review. AORN Journal. January 2018
3. 2022 Hospital National Patient Safety Goals (NPSG). Joint Commission.
4. Lisa Hauk. Avoiding errors when preparing medications in the perioperative setting. AORN Journal Periop Briefing March 208
Is There a Drug Diverter on Your Staff?
Closely monitor your controlled substances and keep them secure.
A former Cedar Rapids, Iowa, surgery center nurse who diverted fentanyl for her own use at a local outpatient surgery center was recently sentenced to five years' probation. Sabrina Thalblum pled guilty to one count of acquiring a controlled substance by misrepresentation, fraud, deception and subterfuge, and one count of adulteration and misbranding with intent to defraud and mislead.
According to the U.S. Drug Enforcement Administration, fentanyl is the most commonly diverted medication. Ms. Thalblum abused her position as an RN to gain access to it at the surgery center.
"Keep in mind that some providers who suffer from substance abuse disorder might not give off any warning signs," says Zachary Bouchat-Friedman, PharmD, a staff pharmacist at Allegheny Valley Hospital in Natrona Heights, Pa. "They're smart and careful and go to great lengths to avoid being caught. That's why it's essential to closely monitor the dispensing and waste of all controlled substances and keep them secure until they're needed."
Dr. Bouchat-Friedman says medication safeguards should be strict and effective. "All controlled substances must be stored separately in a secure location," he says. "Document every dispense and return and require a blind count by a staff member." He says most controlled substances at his facility are delivered to automated storage cabinets, which electronically log dispenses, returns and waste by providers.
Store expired controlled substances in a secure location until they are processed and disposed of by a third party, adds Dr. Bouchat-Friedman, who recommends regular auditing as a safety measure due to anesthesia professionals having such a high incidence of abuse in their profession.
Keep Your Medication Supply Safe
A persistent mix of protocols, technology and awareness can help keep dangerous drugs out of the wrong hands at your facility.
In the wake of the criminal conviction of RaDonda Vaught, who administered the wrong drug and killed a patient, medication safety is top of mind for all healthcare facilities. At surgical facilities, where many potentially dangerous medications are common and plentiful, leaders and staff are on high alert.
Proper medication safety requires surgical leaders to ask some very tough questions: Is there diversion — employees stealing drugs for consumption or resale? Are drugs being properly diluted? Are surgeons overprescribing narcotics or using unapproved new drugs in the OR?
Diversion. All medications should be physically secured so they are only accessible by selected doctors, anesthesia providers and nurses. Locked cabinets are the bare minimum, but a more progressive solution is to lock drugs in a cabinet or room accessible only by a badge swipe, says John Karwoski, RPh, MBA, president and founder of JDJ Consulting in Wenonah, N.J. Anesthesia carts left open after surgery are particularly troublesome. "Educate your anesthesia providers to make sure that before they leave the room, they lock their cart," says Mr. Karwoski.
Doors to rooms where medications are stored should never be propped open, adds Mr. Karwoski, who says badge swiping systems work well here as well. "That way you have an audit trail," he says. "You can get a report from the security company knowing who's entered the room, or if someone tried their badge and didn't gain access, which is a sign someone's trying to get into the room who shouldn't."
Trusted employees can serve as additional eyes and ears. "Staff needs to be knowledgeable about potential diversion, know how to identify red flags and security risks and report to their manager that carts are left open," says Mr. Karwoski, who adds that administrators should tread carefully when receiving these reports. "Know your policy," he explains. "Immediately jump into action, but document all the steps you're taking and everything that's occurring."
One final aspect of a diversion prevention strategy is to always non-retrievably waste unused or expired narcotics. Remainders of partial doses should be destroyed through a chemical or incineration, with a documenting witness. Unopened but expired drugs must be transferred to an approved reverse distributor licensed by the U.S Drug Enforcement Administration.
Medication errors and unapproved drugs. Facilities should maintain a drug formulary that's approved by the governing board, says Mr. Karwoski. In situations where a doctor wants to bring in a drug that has not been screened, leaders can simply point to the formulary as their defense. "If a patient is harmed, and the lawyer says, ‘Doctor, that drug was never even approved to be used here, how did you get it?' that facility might as well shutter their doors right away," he says.
Another danger is that approved drugs can be administered improperly, especially those that in the same cart that look alike or sound alike. Drugs that require dilution before administration can also be patient safety hazards if not prepared properly. "Every drug is dangerous if it's not handled correctly," says Mr. Karwoski.