Outpatient surgery at risk for drug errors
Outpatient surgery at risk for drug errors
Report offers concrete steps you can take now
A recent report on medication errors by U.S. Pharmacopeia (USP) has pinpointed perioperative services as an editor highly at risk for medication errors when compared with the rest of the hospital, and outpatient surgery programs are particularly at risk, say sources interviewed by Same-Day Surgery.
The report looked at more than 11,000 medication errors in the perioperative setting and found that 5% of the errors resulted in harm, including four deaths. This percentage of harm is more than three times higher than the percentage of harm among all medication error records.
"This is a very fragmented system, with multiple handoffs among team members, which reduces effective communication and results in lots of places where the safety net is breached," says Diane Cousins, RPh, vice president of USP's Healthcare Quality Information Department and one of the authors of the report. USP released the report in partnership with the Association of periOperative Registered Nurses (AORN), the American Society of Perianesthesia Nurses (ASPAN), and the Uniformed Services University of the Health Sciences (USUHS).
No one person is tracking the patient through the entire perioperative process, Cousins points out. Every time the patient goes to a new area, such as the preoperative holding area or the OR, there is an entirely new care team. "That type of care tends to have its own issues related to communication and safety net," Cousins says.
The outpatient surgery environment in particular is very fast-paced, says Sharon Giarrizzo-Wilson, RN, MS, CNOR, perioperative nursing specialist in AORN's Center for Nursing Practice. The pace and the noise levels can lead to problems, Giarrizzo-Wilson says. "You've got multiple people communicating very important information," she says. "It's very easy to get distracted."
Giarrizzo-Wilson and others at AORN suggest that nurses also use a verbal active exchange of information regarding medication orders. "If the surgeon orders something, there should be a verbal read back of the order that was written," she says. "The scrub technician or the RN should be validating the medication prior to dispensing it onto the sterile field."
To avoid medication errors, develop strategies to ensure that medications, especially antimicrobial agents, are administered at the correct time. Another proactive step is to expand the pharmacy department's role in perioperative care by having dedicated staff who participate in the medication use process, including reconciling medications and standardizing (or limiting) the products routinely available. Other recommendations from USP for the perioperative area include:
• Developing checklists that are accurately completed prior to patients leaving the area in order to minimize the loss of information through hand-offs.
A lot of institutions have these checklists, says Rodney Hicks, PhD, ARNP, manager of patient safety research and practice at USP and primary author of report. "It's a question of them being filled out," Hicks says. Often, a blank form accompanies the patient into surgery, he says.
• Devising strategies around medications that have a high risk for harm (such as midazolam or other controlled substances) by understanding the causes of these errors.
It's critical to have strategies that prevent errors from miscalculations, especially with pediatric patients, the authors say.
Cousins says, "Children are at particular risk for harm in the four areas related to surgery: [outpatient surgery, preoperative holding area, operating room, and the postanesthesia care unit]." The USP offers strategies for reducing errors in each of those areas.
The report identified pediatric patients, as well as geriatric patients, at being at higher risk of errors. While children comprised 2.6% of the sample, the percent of harm in this population was 12.6%, which is higher than expected, Hicks says. The perioperative area experiencing the highest rates of harm to pediatrics was the post-anesthesia care unit (20.3%).
The greater harm in the pediatric and geriatric populations raises particular concerns for ambulatory surgery centers (ASCs), Giarrizzo-Wilson says. "ASCs do quite a bit of cataract surgery," she points out. "They also get a lot of children for routine procedures, such as tonsils and other ENT cases."
If staff members are administering medications to pediatric or elderly patients, and there will be titration of the medication or a particular concentration that needs to be reconstituted, staff should be especially careful of the calculation, Giarrizzo-Wilson warns.
• Implementing strategies that adequately identify and communicate allergy information and other clinical information to all members of the perioperative team.
Consider having one comprehensive chart that lists allergies, medications, and the patient's weight, Hicks advises.
The Surgery Center at Adena Health Pavilion in Chillicothe, OH, uses a preadmission form that focuses on allergies, medications, systems review, and activity tolerance in order to verify and/or assign an ASA classification, says Michael Burnett, RN, MSA, BSN, clinical manager. "This serves as a form of medication reconciliation because each nurse that cares for the patient during the continuum is required to sign the form," Burnett says. "This form serves as one of the tools used during patient hand-offs."
Many ambulatory surgery patients use herbals and supplements, Giarrizzo-Wilson says. "In the ASC environment, you see patients for a much shorter period of time," she points out. "There needs to be consistency and understanding of potential interactions."
It all boils down to communication, Giarrizzo-Wilson says. "You need to know what's occurring in the patient's medical life prior to surgery and throughout the perioperative experience and then when the patient is charged home," she says. "Otherwise, you can miss potential herbal supplements that can cause life-threatening situations in the periop period."
Resources
To access the report, go to www.usp.org. Under "What's New," click on "USP releases new MEDMARX data report."
The Association of periOperative Registered Nurses (AORN) has tools to assist with medication safety, including the following:
- AORN Position Statement: Pediatric Medication Safety. Web: www.aorn.org.
- AORN Guidance Statement: Safe Medication Practices in Perioperative Practice Settings Across the Life Span. Web: www.aorn.org.
- AORN Safe Medication Practices Tool Kit. Web: www.aorn.org.
The Institute for Safe Medication Practices and the U.S. Food and Drug Administration have a free error-prone abbreviations toolkit that includes an error-prone abbreviations list, a brochure for use in staff education, a print public service ad, a slide show and video that can be used in presentations on the topic. To access a copy of the toolkit, go to www.ismp.org/tools/abbreviations.
A recent report on medication errors by U.S. Pharmacopeia (USP) has pinpointed perioperative services as an editor highly at risk for medication errors when compared with the rest of the hospital, and outpatient surgery programs are particularly at risk, say sources interviewed by Same-Day Surgery.Subscribe Now for Access
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