Perioperative initiatives for medication safety

AORN Journal, Oct, 2005 by Linda J. Wanzer

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed National Patient Safety Goals (NPSGs) to standardize and provide direction for the national movement on patient safety. The third NPSG focuses on safe medication practices, requiring accredited health care facilities to implement strategies focused on removing concentrated electrolytes from unit stock and standardizing and reducing the number of medication concentrations, particularly high-alert medications, available in hospitals and ORs. Goal 3 also recommends an annual review of look-alike and sound-alike medications used in the hospital and OR settings to develop processes to prevent the occurrence of medication errors related to medication mix-ups and standardizing medication labeling practices on and off the sterile field within perioperative and procedure-based settings. (1)

The Joint Commission has outlined numerous strategies that health care organizations can use to become compliant with the NPSG 3 requirements. (2) These strategies represent the beginning of medication safety in the OR, but we can do more to protect patients from medication errors in the perioperative setting.

A review of the literature reveals that additional initiatives have proven effective in reducing medication errors. Such initiatives include instituting satellite pharmacies, using bar coding, and purchasing sterile labeling kits. (2,3) The cost burden for these initiatives can be high, and OR managers are struggling to convince facility finance managers of the economic gain in terms of patient safety associated with these initiatives. A great argument in support of up-front expenditures for patient safety is the philosophy of pay now or pay later in medication litigation costs.

Not all initiatives need to be expensive. Simply separating sound-alike and look-alike medications from each other and separating medications with the same name but different strengths will decrease the risk of choosing the wrong medication. (4) After medications are separated, the bins containing high-alert medications can be labeled with an alert tag, such as a red flag or red dot. Attaching a special label to high-alert medication bins provides a visual reminder to stop, look, and recheck. Automated storage and dispensing systems can provide an added level of safety. Most systems require the user to type in the medication, which causes the user to stop and think about what he or she is taking out of the machine. These systems are not fail safe, however, and they pose the same risks for storing and dispensing errors as regular storage systems, in which look-alike and sound-alike medications and multiple concentrations of the same medication can still be stored side-by-side.

MEDICATION ALLERGIES

The MEDMARX database is a national Internet-accessible database that hospitals and health care systems can use to track adverse drug reactions and medication errors. Both the 2002 and 2003 MEDMARX annual reports identified medication allergies as a causative factor associated with patient harm. (5,6) Technology is great, but not all ORs have computerized systems to cross check patient information for allergy alerts. Until that happens, it could be beneficial to create a low-cost, interim solution by developing an allergy alert reference guide (eg, a laminated reminder) and posting it on the medication storage cabinets and in each OR.

The allergy alert reference guide can list patient allergies in one column, medications to avoid in another column, and suggested alternatives in a third column. Development of this tool could begin with identification of the top 15 medications involved in errors related to patient allergies or medication-to-medication interactions. Perioperative-specific information can be obtained from the United States Pharmacopeia in the analysis of five years of perioperative medication errors data from MEDMARX. (6)

TOXIC DOSE CALCULATIONS

Although the right medications may be administered, data from MEDMARX indicate that harmful errors have occurred as a result of incorrect dose administration and calculations. (6) Do staff members know how to calculate toxic dose limits? This is a team responsibility that requires a team approach. The solution could be as simple as creating and enforcing a policy that requires the team to share toxic dose limit information before the start of a procedure. This way, everyone on the team is aware of what limits not to exceed, and the entire team can become true patient advocates. Another initiative could be to create dosage conversion charts or computer programs to calculate maximum dosage limits. Separate, weight-based conversion charts targeting the top error prone medications for children and adults can be developed.

LABELING POLICY

A good labeling policy can go a long way in managing medications in the OR. No policy, however, is useful unless it is enforced. (7) Policy interpretations lead to deviations in practice, and unless managers perform periodic checks, deviations from policy may go unnoticed and open the door to the occurrence of errors. Observe practices to ensure that policies on safe medication administration are being followed.