Wake-up call—standardization is crucial to eliminating medication errors - Research Corner

AORN Journal, May, 2002 by Suzanne Beyea

Estimates of medication errors suggest that between 770,000 and two million hospitalized patients experience an adverse drug event (ADE) annually, and 140,000 patients actually may die from ADEs. (1) Adverse drug events are injuries that result from the incorrect use of a medication. Morbidity and mortality from ADEs may cost the health care system more than $136 billion annually. (2) Adverse drug events account for the greatest percentage of procedure-related malpractice claims. (3) These shocking and distressing facts make ADEs a focus for patient safety efforts.

MEDICATION ERRORS IN THE OPERATING ROOM

The specific problem of medication errors and adverse events in the OR has not been addressed or studied fully; thus, there is a limited understanding of the magnitude and seriousness of these types of errors. Perioperative team members must acknowledge that serious medication errors can and do occur in the OR even if they never have been involved in an medication mishap themselves. The evidence is obvious based on the published literature, nightly news, and numerous malpractice cases addressing the problem.

For example, a recent Dateline report reviewed the case of Ben Kolb, a seven-year-old boy in Florida who died as the direct result of receiving local adrenaline instead of lidocaine with epinephrine during administration of a local anesthetic for ear surgery. Other examples of medication or solution mishaps include using the incorrect strength of lidocaine, (4) administering chlorhexidine gluconate intravenously, (5) injecting formaldehyde during cosmetic blepharoplasty, (6) and infusing dobutamine instead of metocurine. (7)

Reported errors involve a variety of clinicians, including surgeons, anesthesia care providers, nurses, and assistants. Many question why theses errors happen and whether they occur as the result of careless practices. These errors, regardless of the type, occur as the direct result of system errors, not through intentional malfeasance on the part of health care providers. Medication errors in the OR that result in adverse events happen for various reasons, including

* misidentification of medications or solutions;

* outdated preference cards (ie, physician orders);

* inadvertent intravascular or organ infusion of a potentially toxic substance;

* infusion and infusion device problems;

* timing of medication administration, specifically preoperative antibiotics;

* miscommunication of verbal orders; and

* unusual surgical practices or situations (eg, surgeon practices, emergencies).

THE OPERATING ROOM IS UNIQUE

To solve the problems that result in ADEs, practitioners must fix the system. Although many experts recommend computerized documentation as a primary strategy for reducing medication errors, computerization promises only limited help in addressing problems specific to the OR. Recommendations for safely ordering and administering medications provide little guidance for OR-specific

strategies to promote safe medication practices.

It is important to recognize that the OR is a unique environment compared to the typical inpatient clinical unit. The nature of practice requires that medications and solutions be delivered aseptically to the sterile field. System problems, such as inconsistent practices, unclear written policies, and lack of training or education, can increase the risk of a patient receiving an unintended medication or solution. Product packaging that prevents delivering a medication aseptically to the sterile field in its original container and labeling that is inconsistent, difficult to read, or similar for extremes in dosage also can contribute to medication errors. To reiterate, these all are system errors.

RESOLVING ERRORS

How are system errors like these addressed and resolved? First, it is critical to establish policies and procedures for handling medications and solutions. Safe medication and solution handling and administration requires standardization of clinical practices. Ideally, a set of safe practices specific to surgery should be adopted in every OR in the United States and worldwide. Clinicians cannot assume that an error will not occur in their OR. Egregious errors can and do occur in almost any clinical setting. All clinicians must work together to prevent the next error.

Developing consensus and using a set of safe practices for medication handling and administration will result in significant practice changes by clinicians. Although some may believe they are exempt from adopting such practices, clinicians must work together to standardize and error-proof all clinical processes. Safe medication handling in the OR requires teamwork and collaboration. Surgical team members must collaborate to determine and establish safe practices based on the best information available.

For many clinicians, raising the bar may feel unnecessary, but improving practice should reduce the potential for error. Consider that, for decades, clinicians used local standards for resuscitating patients in cardiac arrest. They performed resuscitation the way they were trained and made up rules based on personal experience and very little scientific evidence. Cardiopulmonary resuscitation (CPR) emerged as a national standard in the 1960s and, subsequently, was widely accepted and used. (8) This resulted in a standard of care and process that minimizes the inherent risks of providing cardiac compressions and artificial respirations. Experts concur that the evolution of CPR also was wrought with a history of human error and discovery. (9)