Differences in perioperative medication errors with regard to organization characteristics

AORN Journal, Feb, 2006 by BradLee Goeckner, Michael Gladu, Janet Bradley, Sandra C. Garmon Bibb, Rodney W. Hicks

Medical errors resulting in preventable adverse events have been reported to be the eighth leading cause of death in the United States/ and it is projected that one in every 10 patients entering a hospital will experience some form of harm that results in severe disability or death? A landmark report by the Institute of Medicine (IOM), To Err is Human: Building a Safer Health System, estimated that between 44,000 and 98,000 people die annually from preventable medical errors. (1) Another report estimated that as many as 195,000 people die each year from preventable errors that occur in hospitals. (3) Medication errors contribute significantly to the total number of overall medical errors and deaths associated with preventable medical errors. According to the IOM report, more than 7,000 Americans die annually from medication errors across the health care system. (1)

The total estimated cost of medical adverse events, including medication errors, lies somewhere between $6 billion and $29 billion annually. (1,2,4) Adverse drug events increase patients' average length of hospital stay by 4.6 days at an estimated cost of $4,700 per admission, (1) and the average cost of litigating a malpractice claim involving an inpatient adverse drug event is approximately $376,500. (5) In addition to monetary costs, there are human, professional, and organizational consequences associated with medication errors. The consequences of medication errors can cause temporary or permanent harm to patients, result in lost productivity for patients and their family members and caregivers, increase malpractice premiums, and affect overall confidence in the clinical skills of practitioners who commit errors. (6)

Existing literature and reported frequency data related to medication errors may be insufficient to provide health care organizations with the type of information they need to address perioperative medication errors at the organizational level. Additional research is needed to investigate the relationship of organization characteristics to the occurrence of medication errors across the perioperative continuum. This article reports the findings of a study conducted to identify differences in medication errors across the perioperative continuum of care (ie, same day surgery [SDS], preoperative holding area, OR, and postanesthesia care unit [PACU]) with regard to organization characteristics.

LITERATURE REVIEW

There is limited literature describing medication errors that involve the perioperative continuum of care. The majority of the literature has focused on a narrow clinical area within this continuum. Researchers who performed a secondary analysis using 18 months of data reported to MEDMARX--a voluntary, anonymous, medication error reporting program owned, operated, and managed by the United States Pharmacopeia (USP)--identified 610 medication errors specific to SDS. (7) Although the majority of errors did not result in harm, 3.7% of the errors did result in patient harm. (7) These researchers also performed another secondary analysis using the same 18 months of MEDMARX data and identified 731 medication errors specific to the OR. (8) They reported that 10% (n = 73) of the errors resulted in temporary harm, permanent harm, or patient death, (8) and they concluded that medication errors were prevalent in the OR and were significantly harmful when they occurred. The researchers recommended further investigation of medication errors that occur across the perioperative continuum of care.

Another group of researchers conducted a study using the same 18-month MEDMARX data set to evaluate PACU medication errors. In this study, the researchers found that of the 645 medication errors reported in the PACU, 6.8% (n = 44) resulted in temporary harm, permanent harm, or patient death. (9)

Early in 2004, a group of perioperative clinical nurse specialist graduate students completed an in-depth analysis of a five-year data set to identify medication error characteristics occurring within the entire perioperative continuum of care. They found that between Sept 1, 1998, and Aug 31, 2003, 413 of the 691 facilities subscribing to MEDMARX reported a total of 5,210 medication errors occurring in one of the four perioperative continuum of care locations. (10) Each medication error report in MEDMARX was associated with several medication error characteristics. Of the 5,210 perioperative medication errors, 333 (6.4%) were classified as errors that may have contributed to or resulted in patient harm or death. (10) As with the harm rates derived from analyses of the 18-month data set, analysis of five years of existing medication error data yielded a harm rate that was significantly higher than the national harm rates reported in 2001 (ie, 2.4%) (11) and 2002 (ie, 1.67%). (12) In addition, the harm rate for each of the four clinical areas exceeded the national averages. When overall percentages of errors were examined, two areas--the OR and PACU--disproportionately accounted for 81% of all medication errors reported to MEDMARX within the five-year time frame. (10)