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By: , Rodney Hicks, Shawn Becker, Diane Cousins
Published: 10/10/2007
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 | ||||
Location |
Outpatient Department |
Pre-op |
OR |
PACU / Recovery |
Total errors examined |
3,427 |
779 |
3,773 |
3,260 |
Pediatric errors |
84 |
24 |
126 |
59 |
Adult errors |
1,081 |
239 |
1,272 |
1,135 |
Geriatric errors |
606 |
151 |
689 |
613 |
Unspecified age errors |
1,656 |
365 |
1,686 |
1,453 |
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.
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:
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:
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.
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:
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.
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