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Making All the Right Moves
How to prevent medication errors every step of the way in your facility.
, Rodney Hicks, Shawn Becker, Diane Cousins
Publish Date: October 10, 2007   |  Tags:   Patient Safety

A 64-year-old patient in the pre-operative holding area was awaiting surgery for carpal tunnel repair. A nurse started the patient's IV line and concluded the patient examination and interview. The anesthesia provider then saw the patient. He intended to administer midazolam, famotodine, metoclopramide and ondansetron, but inadvertently swapped syringes and administered succinylcholine instead. The error resulted in immediate respiratory paralysis to the patient, who was transported to the OR for intubation and general anesthesia.

Medication Errors at a Glance


Outpatient Department



PACU / Recovery

Total errors examined
Percent with harmful outcomes





Pediatric errors
Percent with harmful outcomes





Adult errors
Percent with harmful outcomes





Geriatric errors
Percent with harmful outcomes





Unspecified age errors
Percent with harmful outcomes





SOURCE: Medmarx Data Report, 1998-2005

This was just one of more than 11,000 surgical medication errors that nearly 900 hospitals reported to U.S. Pharmacopeia's Medmarx database between 1998 and 2005. In this case, the error nearly cost the patient her life. In about 5 percent of the errors, the wrong drug, wrong dose, wrong time, wrong administration or omission of a drug caused direct harm to the patient and, in four cases, contributed to or directly caused patient deaths.

The physician gave a verbal order for 100mcg fentanyl and 1mg midazolam. The nurse confirmed the order but incorrectly administered the drugs. After 11 minutes, the elderly female patient was unresponsive and a team rushed to save her life with naloxone and supplemental oxygen.

The types of medication errors that were found to occur - and, consequently, our recommendations for prevention, published in the 2007 Medmarx Data Report - varied depending perioperative setting of the error as well as the patient's age group (pediatric, adult or geriatric). Several recommendations, however, were common to all locations and ages, including the following.

  • Ensure that medications, especially antimicrobial agents, are administered at the correct time, as the timing of a drug's administration has a significant impact on its efficacy.
  • Implement strategies that adequately communicate accurate patient information to all members of the perioperative team. Our study found that the perioperative continuum of care is in many cases a fragmented one and that handoffs between practitioners coupled with breakdowns in communication, inaccurate or missing documentation and distractions led to lost patient information.
  • Explore the role that dedicated pharmacists can play in perioperative care, particularly in preventing errors from occurring. Our study found that 739 products were associated with at least one error, but that of this number, only 165 were involved in errors resulting in harmful outcomes. The drugs most frequently associated with harmful events include morphine (12.3 percent), fentanyl (6.6 percent), cefazolin (5.4 percent), meperidine (5.4 percent) and heparin (4.9 percent).
  • Call upon manufacturers to provide drug products in ready-to-use packaging, especially for the OR, and in appropriate doses, especially for the pediatric population. Our study showed that children, regardless of perioperative setting, were often given an incorrect amount of medication.

The surgeon wrote an order for hydroxyzine and specified the route as intravenous, rather than intramuscular. The nurse didn't catch the error and administered the drug intravenously.

In outpatient departments, nearly half (49.8 percent) of the medication errors occurred during drug administration, with another 29.6 percent involving prescribing, 11.4 percent involving transcribing or documenting and 8.3 percent involving dispensing. Broken down into particular actions, incorrect or inaccurate prescription counted for 27.7 percent, dose omissions for 23.6 percent, improper dose or quantity for 19.6 percent and unauthorized or wrong dose for 14.3 percent. Incorrect administration was the error most often cited in errors resulting in harmful outcomes. Many of the errors were the result of miscommunication, a finding that was 1.5 times higher in the outpatient department category than in the general data set.

Our recommendations for reducing medication errors in hospital outpatient departments are aimed at reducing the loss of pertinent clinical information and addressing system level changes that contribute to the efficiency of the perioperative process. Facilities should enact these policies:

  • Adopt a culture of safety that integrates safe medication practices, beginning with medication reconciliation to evaluate and assess patients' prescriptions and allergies at the time of admission.
  • Examine prescribing practices to ensure that pre-op orders are unambiguous and complete, perhaps by adopting pre-printed order forms that include antimicrobial orders to make sure that alternative products are available in the event of patient allergies.
  • Expand the role of the pharmacy staff to include reviews of pre-op orders and assistance in implementing safe medication use practices such as barcoding.
  • Build an easy-to-use medication administration record that employs smudge-proof laser-printed labels in a readable font size; integrated checklists for accurate, routine reporting; and standardized documentation to avoid marking physicians' orders as "given."
  • Involve your patients and their family members or advocates in your pre-procedural safety activities such as gathering and reviewing pre-registration information, medication reconciliation, a discussion of the upcoming surgical process and the marking of the surgical site.
  • Provide patients with complete written instructions upon their discharge, including the name of the medication, its dose, its frequency and any potential adverse effects that will require monitoring.

At the beginning of a case, the anesthesia provider asked the student in training to administer the paralyzing agent. The student gave the medication via the arterial line instead of the IV line. The error was detected immediately: The anesthesia provider intervened and aspirated the arterial line. No permanent injury resulted.

In pre-op, 57.5 percent of medication errors occurred during drug administration and 21.9 percent during transcribing or documenting. The two leading types of errors in this area involved either doses given at the wrong time (37.7 percent) or not at all (29.7 percent). About 35 percent of pre-op errors resulted from inaccurate or incomplete documentation, nearly three times higher than expected. Patient transfer and distractions contributed to another one-third of the errors.

Considering the key role pre-op plays in staging, patient flow and the surgery schedule, the recommendation of open and accurate communication between the pre-op staff and other intraoperative personnel cannot be overemphasized. Medication errors that occur as a result of incomplete information or the incorrect insertion of invasive lines can cause significant patient safety risks at worst, and at the very least throw off the day's schedule. Pre-op staff should be responsible for these tasks:

  • Correctly verify the patient and the procedure for which she's scheduled.
  • As the aforementioned case in which the anesthesiologist inadvertently swapped syringes and accidentally administered a neuromuscular blocking agent in pre-op demonstrates, you should ensure that the correct drugs are administered.
  • Begin infusing antimicrobials, administered according to guidelines and at the proper pace, if they haven't already been given.
  • Enlist the pharmacy department to assist in reviewing pre-op orders, ensuring medications are readily available at the time they're needed, and serving as a resource for non-routine orders.

A dose of cefazolin was requested at the end of a surgical case involving a 55-year-old male. An unlabeled medication was given. The patient complained of not being able to breathe. As a result of the patient's condition, the patient was provided supplemental oxygen and reintubated. It was concluded that vecuronium was given instead of cefazolin.

In the OR, more than half (56.3 percent) of surgical medication errors occurred during drug administration and 20.1 percent during prescribing. One unusual finding was that a high percentage of errors (20 percent versus a historical average of about 12 percent) involved the use of the wrong drug. In many instances, patient allergies were completely overlooked when ordering or administering a medication.

Since medication errors in the OR can result in increased morbidity and mortality, these recommendations should be priorities.

  • Practitioners should have ready access to accurate patient information, including the patient's weight (documented in kilograms to eliminate conversion calculations) and surgical history.
  • Frequently review physicians' drug preference cards. Note the date of the last review or revision, and avoid abbreviations or acronyms. To the extent that you can, adopt electronic drug ordering technology to eliminate errors and double check for interactions, allergies and dose discrepancies.
  • As medications are prepared and passed, verbal communication between circulators and scrubs should be clear and involve a repeat-and-verify practice.
  • Staff should confirm the labeling of drugs, which should be done in accordance with accepted safety standards and should accommodate the needs of the anesthesia provider and sterile field staff.
  • If possible, have dedicated satellite pharmacies in the perioperative area to assist with the preparation of drugs, the review of orders and the maintenance of automated dispensing devices.
  • Call upon drug manufacturers to supply products in ready-to-use packaging with sterile, duplicate labels.

A surgeon ordered morphine
0.5mg every five to 10 minutes as needed, with a maximum of 2mg, for post-op pain control in a school-age child. The nurse providing care was distracted and miscalculated the dose and administered 5mg every five to 10 minutes. The patient became unresponsive. An anesthesia provider was called and the child was given naloxone. The child received six additional hours of observation and monitoring before being released from the PACU.

In the PACU, once again administering drugs (50.3 percent) and prescribing them (28.4 percent) led the list of error areas. Broken down by action, prescribing was cited in 24 percent of errors, wrong amount in 21.3 percent, dose omission in 19.2 percent and unauthorized or wrong drug in 14.7 percent. The PACU study indicated a higher than expected percentage of errors resulting from staff not following policies and procedures (26 percent versus a historical average of 18 percent), as well as a higher percentage of errors involving medications for which the patient had a known allergy. Our recommendations for the PACU include these:

  • Given the importance of patient-controlled analgesia to PACU, closely monitor the programming and use of PCA systems to ensure their adequate and efficient operation. Our study found many errors resulted from improper programming of these devices.
  • Further, some errors involved misadministration of PCA drugs due to the incorrect connection of device tubing. Negotiate with device manufacturers to incorporate forcing functions that prevent tubing misconnections.
  • Doses must be calculated correctly. Work with your pharmacists to provide weight conversion charts that illustrate maximum dose limits. Such charts must clearly distinguish between volume and dose.

Bridging the gap
Our study indicates that there is fragmentation within the perioperative continuum of care that often leads to patient harm. Incorporating our recommendations into your facility's care plans and your providers' protocols and procedures will go a long way toward bridging the gaps in your perioperative process, preventing medication errors from causing patient harm and providing a safer healthcare environment.