AORN guidance statement: safe medication practices in perioperative settings across the life span

AORN Journal, August, 2006

INTRODUCTION

This guidance statement provides a framework for perioperative registered nurses to develop, implement, and evaluate safe medication management practices specific to the perioperative setting. This evidenced-based framework may be used to facilitate policy development and provide a foundation for the creation of quality improvement (QI)/ process improvement (PI) monitors. It is the responsibility of individual health care organizations to develop a culture of medication safety. Proactively reviewing medication errors from the viewpoint of "systems failures" and "systems solutions" will help encourage a culture free from shame and blame.

Perioperative practice settings addressed by this document include traditional operating rooms, ambulatory surgery units, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where operative and invasive procedures may be performed. For the purpose of this document, the term OR is inclusive of all perioperative practice environments.

First published in May 2002, the current guidance statement has been reviewed and updated by AORN's Presidential Commission on Patient Safety, in collaboration with the United States Pharmacopeia (USP), to reflect current safe medication practices.

BACKGROUND

The National Institute of Medicine report To Err Is Human: Building a Safer Health System increased awareness of medication errors. (1) The report noted that "medication errors account for one out of 131 outpatient deaths and one out of 854 inpatient deaths." (1) (p27) Medication errors can originate at any point in the medication use process and affect patients of all ages. Medication error poses a substantial threat to patients. The perioperative setting creates additional challenges for safe medication administration practices.

Related factors affecting the medication process in the perioperative environment include

* the aseptic dispensing of medications onto the sterile field;

* an intermediary to receive and transfer dispensed medications to the scrubbed licensed practitioner (eg, surgeon);

* time-sensitive conditions; and

* sensory distractions intrinsic to the environment.

Specific concerns associated with medication errors in the perioperative setting include, but are not limited to,

* inconsistent practices to communicate current and previous medication regimes (ie, medication reconciliation);

* verbal orders delivered through surgical masks that may be muffled and contribute to confusion in the medication order (eg, name, strength, dose);

* incomplete, ambiguous, incorrect, or illegibly written or spoken orders;

* inaccurate, illegible, or outdated surgical preference cards;

* removal of the contents from the original manufacturer's packaging to aseptically deliver contents onto the sterile field;

* limited knowledge of medications by scrubbed allied heath professionals receiving medications onto the sterile field;

* inconsistent labeling of medications on and off the sterile field;

* medication dispensed to the sterile field that may be handled by multiple individuals before reaching the licensed individual administering the medication;

* high-alert medications available in multiple dose forms and concentrations;

* look-alike and sound-alike medications stored in close proximity;

* patient care complexity requiring rapid perioperative interventions;

* extended work hours leading to health care provider fatigue;

* care provided by multiple health car providers simultaneously; and

* multiple patient hand offs between care providers.

The following guidance is offered to support perioperative registered nurses in the provision of safe perioperative patient care.

GUIDANCE STATEMENT

Health care organizations should identify in policy which people and/or job categories may participate in medication management and administration. Facility policy for safe medication practice should be based on the five "rights" of medication administration:

* right patient,

* right medication,

* right dose,

* right time, and

* right route.

The five rights of safe medication practices should be a final check before the administration of any medication.

Health care organizations should develop standardized procedures for safe medication practices in the OR that are designed to include, but not be limited to, the following.

* Ensure proper patient identification.

* Document all patient medications.

* Assess for medication(s) contraindications.

* Confirm weight-based dosing before administration.

* Establish dose limits.

* Minimize use of verbal orders to the extent possible.

* Manage medications off the sterile field.

* Deliver medications to the sterile field.

* Manage medications on the sterile field.

* Document all intraoperative medications.

* Monitor and document patient for effects of medications.

* Preserve all original medication/solution containers and delivery devices until the conclusion of the procedure.

* Continually evaluate the medication delivery process for patients within the surgical setting.