Be prepared — Don't let errors with medications happen on your watch

A patient arrived from an assisted living facility with a documented allergy on the chart. Despite this safeguard, the patient still received an incorrect medication prior to the procedure. Fortunately, in this case, there was no lasting harm to the patient.

"Frequently, as with any medication error, it's a process issue, not just one individual," says Charlotte Huber, RN, MSN, senior patient safety analyst at ECRI Institute, a Plymouth Meeting, PA-based nonprofit organization that researches approaches to improve patient care. ECRI helped produce the Pennsylvania Patient Safety Advisory for the Pennsylvania Patient Safety Authority in Harrisburg, which recently reported on medication errors in ambulatory surgery facilities (ASFs) in the state. The mandatory reporting is required by the state.

Huber thinks this error with the patient from assisted living involved one particular mode of the medication process: medication reconciliation. "What's interesting about outpatient surgery — certainly what makes that setting vulnerable to more medication errors — is that the success of outpatient surgery heavily relies on the quality of patient information," she says. "This patient information is supplied by many sources: the surgeon, primary care physicians, and in this particular example, assisted living — or even a patient."

If information isn't relayed to the providers, or the patient isn't able to provide reliable information, an allergy or other important information can be missed, Huber says. Keep in mind that patients can be allergic to over-the-counter medications, herbal remedies, or vitamins, she says. "If it's not communicated or reconciled with the outpatient surgery clinic, you can have some problems, and certainly an issue such as this [overlooking allergy information] can occur, Huber says.

One way to avoid overlooking allergy information is to ask patients what reaction they had, says Matthew Grissinger, RPh, FISMP, FASCP, director of error reporting programs at the Institute for Safe Medication Practices (ISMP) in Horsham, PA, which helps produce the Pennsylvania Patient Safety Advisory, and senior patient safety analyst for the Pennsylvania Patient Safety Authority.

Also note that reactions can range from an upset stomach to death, Grissinger points out. "Many providers see that a patient has an allergy, but they don't see the reaction, so they make a decision with incomplete information," he says.

Monitoring error/documented allergy was one of the most common types (17.1%) of medication errors reported to the Pennsylvania Patient Safety Authority from June 28, 2004, through Dec. 31, 2010.1 Others included drug omission (26.7%) and the wrong drug (22.3%). Pennsylvania ASFs submitted 502 medication error reports to the authority from June 28, 2004, through Dec. 31, 2010. Pennsylvania had 265 licensed ambulatory surgery facilities (ASFs), which performed more than 960,000 procedures between July 1, 2008, and June 30, 2009, according to the Pennsylvania Patient Safety Advisory. ASFs reported that 3.6% (18) of the events resulted in patient harm, which compares to 0.6% of medication error reported by acute care facilities.

On the plus side, outpatient surgery facilities might find it easier to focus on avoiding medication errors because generally they are not using as large a variety of medications as a hospital is. However, the "business aspect" of outpatient surgery, having one case immediately following another, could be to its detriment, Grissinger says. "The minute something goes wrong and you are 15 minutes late, that sets the tone for the rest of day, in terms of playing catch up to get things done on time," he says. "That's the nature of the beast."

Both inpatient and outpatient settings fall prey to not using double checks, he says. "It's so simple to do a little double check," Grissinger says. "Real serious events can be caused by not shoring up that process."

With a verbal order, the only person who understands the order or knows the intent is the prescriber, he points out. "If there is no double check, you're assuming you got the right thing," Grissinger says.

Ongoing staff competencies and an on-site pharmacist also can assist with medication reconciliation issues, Huber says.

The best say to avoid medication errors? Accuracy, Huber says, "not just figuring out their first and last name or their demographics, but their history, having medication reconciliation, having an assessment of risks and other illnesses, asking the patient the reason for surgery, and getting an accurate patient screening." (See more tips,below)

Reference

1. Grissinger M, Dabliz R, Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania. Pennsylvania Patient Safety Advisory 2011; 8:85-93.

Resources

  • The September 2011 Pennsylvania Patient Safety Advisory contains "A review of medication errors in ambulatory surgery facilities (ASFs)." For the advisory, go to www.patientsafetyauthority.org. Under "Patient Safety Advisories," select "Advisory Library," then the September 2011 issue.
  • For an updated List of Confused Drug Names from the Institute for Safe Medication Practices (ISMP), go to http://www.ismp.org/Tools/confuseddrugnames.pdf. The Joint Commission web site no longer maintains a look-alike/sound-alike medication list.

Most common? Antibiotics omitted

Steps you can take now

In a recently released advisory on medication errors at ambulatory surgery facilities in Pennsylvania, the most common drug omissions were patients who needed antibiotics before surgery.1

Often these omissions occur due to breakdowns in communication of the drug order, says Matthew Grissinger, RPh, FISMP, FASCP, director of error reporting programs at the Institute for Safe Medication Practices (ISMP) in Horsham, PA, which helped produce the Pennsylvania Patient Safety Advisory, and senior patient safety analyst for the Pennsylvania Patient Safety Authority in Harrisburg, which published the advisory.

For example, the advisory reports a case in which an elderly patient was admitted for a procedure, and the preoperative orders were transcribed by the admitting nurse. After the nurse transcribed the orders, the physician prescribed a preoperative antibiotic. The nurse wasn't notified verbally. The PACU nurse determined that the order was not given and notified the physician. The antibiotic was administered in the PACU.

To avoid cases such as this one, consider standardized orders that include the possibility of giving antibiotics, Grissinger advises. "The order should be standardized or protocols should be standardized, with at least a suggestion of giving antibiotics on the order form, versus expecting a doctor to remember writing it every time," he says.

Errors of omission also can occur because the patient isn't able to communicate or because of patient misidentification, says Charlotte Huber, RN, MSN, senior patient safety analyst at ECRI Institute, a Plymouth Meeting, PA-based nonprofit organization that researches approaches to improve patient care. ECRI helped produce the Pennsylvania Patient Safety Advisory. For example, a nurse will walk into a room where there are three people and ask, "Are you John?" The wrong person answers.

Here are some of the other most common medication errors in outpatient surgery, along with tips on how to address them:

• Drugs confused.

In the ambulatory surgery medication error report, there were a significant number of reports of eye drops being mixed up, says Grissinger, who acknowledges that the large number of eye cases performed outpatient contributes to the number of errors.

Providers might experience mix-ups between similar-looking eye drops or mix-ups between injectable products for a variety of reasons, he says. Standardization can help avoid problems, he says. "Look at the big picture in your ASF, the drugs you have in stock," Grissinger says. "Confirm what you need and don't need, so you have some standardization on the types of medications."

Limit the varieties of concentrations as well, he says. Also examine how they are stored, Grissinger says. "If you have two eye drop bottles, and you store them next to each other, someone will choose the wrong one at some time or another," he says. "People in healthcare aren't good about looking proactively at what could go wrong. They're often in the business of 'putting out fires' versus putting good strategies in place."

Another problem that causes medication errors is confusing look-alike, sound-alike medications. Huber says. (See Resources, above, for information on updated list of confused drug names.)

Lack of labeling medications.

In outpatient surgery, providers sometimes neglect to label medications, Grissinger says.

"They may draw up a syringe of drugs, put it down, and come back," he says. "Or they might get a vial of a product and pour the contents into a stainless steel bowl, to draw up in a syringe." Patients have died, because a bowl with a clear solution wasn't labeled, Grissinger says.

Missing documentation.

"There are many pieces of patient information that are essential to be sure surgery is successful," Huber says. Those pieces include paperwork from the primary care provider, including lab tests, and the history & physical.

Checklists are "wonderful" tools to ensure no pieces of the documentation are missing, she says. Huber points to the World Health Organization (WHO) Surgical Safety Checklist as one that is useful. "Consider using that during patient sign in, the timeout, and sign out, which is immediately after surgery," Huber says. (Editor's note: The WHO checklist can be accessed at http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html.)

Keep in mind that anesthesia staff members need to conduct interviews and examinations, because those providers are introducing medications as well, she points out.

Also, study near misses with medication, Huber says. "Those are a really great opportunity for facilities to learn from some of their processes and issues they have, to see how they're prevented, and to share them regularly with staff," she says.

Resources

  1. Grissinger M, Dabliz R, Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania. Pennsylvania Patient Safety Advisory 2011; 8:85-93.