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Reducing Medication Errors in the OR

Most health care professionals are familiar with the Institute of Medicine's report To Err Is Human: Building a Safer Health System, which suggests that 98,000 annual deaths are attributable to errors made by health care personnel.1 Since the release of that report in November 1999, researchers have continued to study errors in health care. In 2016, Makary and Daniel2 suggested that there may be as many as 251,000 annual patient deaths attributable to health care errors.

 

Reducing Medication Errors in the OR

For example, medication errors still exist despite the examination of why they occur and the creation of steps or processes to reduce them. From 1995 to 2010, The Joint Commission reviewed 7,147 sentinel events that affected 7,288 patients.3 Errors in medication administration accounted for 563 (7.9%) of these events.3 For the calendar year 2014, 18 of 764 reported sentinel events were directly related to medication administration, accounting for 2.4% of all reported sentinel events.4 These statistics illustrate that medication errors occur and can be devastating to patients. Many events, including medication errors, are not severe enough to require reporting to The Joint Commission as sentinel events, however. Therefore, the available statistics may not represent the scope of errors that occur.

Medication Administration

Discussion about appropriate medication administration varies. Some sources state that medication should be administered to the patient according to five basic “rights” (ie, the right patient, right medication, right dose, right route, right time).5, 6, 7 One source cites more rights, expanding the list to include the right of refusal, right knowledge, right questions or challenges, right advice, and right response or outcome.6 Another source suggests changing the model to include greater consideration of the patient and the nature of the administration system, and recognizing that medication administration is a task that involves many components.5 Federico7suggests that the five rights is more of a framework or guideline and that the five rights cannot be the only criteria used to evaluate correct medication administration by the provider, because they do not account for human error and systems issues. Despite the differences of opinion about these rights, many of the strategies employed or suggested to help eliminate and reduce medication errors are aimed at ensuring nurses and other health care providers have addressed the five rights of administration.

Using Technology to Reduce Errors

Several technological methods have been developed and studied as means to help reduce errors. One method is computerized order entry.8 In many facilities, electronic medical records have replaced paper charting and paper order entry. Additionally, for nonemergent needs, many facilities have reduced the acceptance of verbal or telephone orders from providers. Health care providers also have implemented technology for bar code scanning to help deter errors.8 To use this technology, the person administering a medication scans the bar codes on both the patient’s name band and the medication and may be required to follow system prompts as indicated in the electronic medical record’s medication administration section (eg, enter current blood pressure or heart rate to ensure that the medication is appropriate and timed correctly).

Bar code technology helps reduce errors, but it also may cause issues (eg, hardwired scanners that require tethering the scanning device to a computer make accessing a bar code difficult). In addition, bar code technology assumes that the patient’s name band is correct and that the medication to be scanned and administered is correctly labeled.8

Using a Team Approach to Reduce Errors

The Agency for Healthcare Research and Quality recommends using a multidisciplinary team approach (eg, physicians, pharmacists, advanced practice providers, nurses) to improve patient safety and medication administration.8 Including pharmacy personnel on this type of team allows them to verify orders and dispense medications as part of their routine workflow. A pharmacist can review a specific order and any other orders for that patient, allowing him or her to ask questions about the medications ordered or request additional information or tests to prevent medication conflicts. Pharmacy personnel can review and approve nonemergency orders before the order moves from a pending status to a medication ready for administration.

Another team process to help reduce errors is dual sign-off for medication administration. This method requires a second nurse to review the order, the intended patient, and which medication is to be administered, confirming that everything is correct.9 The Institute for Healthcare Improvement recommends dual checks or sign-offs for certain classes of high-risk medications (eg, anticoagulants and sedatives) to help reduce the errors associated with administration of those medications.9

Application to the Perioperative Setting

Perioperative staff members can employ efforts such as bar code scanning, computerized order entry, pharmacy personnel review of orders, and dual sign-off on high-risk medications in the perioperative environment. Bar code scanning and pharmacy review are most easily applied in the preoperative and postoperative environments. Physicians often place preoperative orders on the patient’s electronic medical record before his or her admission, and pharmacists can easily review them. Many postoperative orders can be reviewed in a similar manner.

Staff members can also review some orders meant for intraoperative administration if the medications are routinely needed for a specific procedure. In the intraoperative environment, if required by the facility, an attending physician must place orders for chemotherapeutic agents or other high-risk medications, and pharmacy personnel must verify and dispense them before the RN circulator is able to administer or document those medications. In addition, not all medications are available at all times. Some electronic medical records systems display medications not yet ready for administration differently than scheduled and verified medications.

In the OR, enforcing a blanket rule that all orders must be entered by the provider and verified by pharmacy personnel does not take into consideration that not every medication needed can be anticipated. Although there are medications that each provider tends to use for specific procedures that may be handled in this way, the plan of care does not always progress as expected. It is not realistic to ask a surgeon to stop a procedure to order a medication he or she did not anticipate needing. Communication between the RN circulator and the surgeon is vital to ensuring that needed medications are available.

Bar code scanning is a valid measure to improve patient safety but is limited in several ways. Scanners that must be tethered to a computer would not work as easily as wireless scanners in the OR. If the patient is positioned in a manner in which his or her name band is not accessible, personnel may be unable to use the scanner or may have to create some type of workaround. To circumvent these issues, staff members may print multiple identification bands so they can scan the patient band without it being attached to the patient, or they may simply override a safety feature - which can lead to errors. In addition, many studies addressing medication administration, medication errors, and methods to prevent medication errors have been studied primarily in nonperioperative environments; therefore, the techniques and recommendations to reduce errors may be difficult to implement in the OR.

Perception and Bias

Perception is defined as “a result of perceiving” as well as a “capacity for comprehension.”10 The definition of bias is “an inclination of temperament or outlook; especially: a personal and sometimes unreasoned judgment.”11 These definitions suggest that perception and bias are specific to each individual. Human nature is a factor in all interactions, including those in health care, and humans are prone to error. The fact that health care providers may perceive issues differently may be an additional reason for the difficulty in reducing medication administration errors. The experiences of health care providers affect their opinions, perceptions, biases, and judgments. Such perceptions and biases persist, so providers may have differing views on what constitutes an error, the likelihood of making an error, and how to reduce the potential for error.

Definition of Errors

Perception affects an individual’s definition of an error. One definition of an error is anything that deviates from policies and procedures; however, definitions can also vary depending on an individual’s beliefs and practices.12 Some providers may believe that only a sentinel event is an error, and other providers may include near misses as errors. These differing definitions can contribute to miscommunication and a lack of attention to events that should be examined, even if the patient was not harmed.

The Likelihood of Making an Error

The belief that errors will not happen to us manifests itself in comments such as “If he had [done this and not that], then the error would not have occurred,” or “I always [perform a specific clinical task in a specific way]; therefore, I would not have made that mistake.” Statements such as these can be damaging, because they encourage a sense of superiority while providing a false sense of security. It is important for health care providers to accept that everyone makes mistakes and that adherence to recommended practices and policies helps prevent mistakes. Attention to practice deviations is important because those deviations can result in errors.13

Perceptions of Pain

Illustrating the effect of potential differences in perception, consider pain management and the perception of pain. Perception and bias can affect medication administration. For example, a patient’s perception of pain and the outcomes of pain management efforts are affected by both the patient’s and the providers’ perceptions and biases. Ultimately, pain is what a patient says it is, regardless of what a nurse or other provider may believe about a given situation. Providers may question whether a patient’s description of his or her pain is as severe as reported, however. One patient may not experience pain in the same manner as another patient or the provider, and this difference may influence how the provider provides pain relief.

Conclusion

Statistics associated with health care errors show that the number of errors and patients harmed by these errors is not shrinking,2 although reporting of medication error–associated sentinel events has decreased.3, 4 Using technology and a team approach may help reduce medication errors as well as other errors. When assessing medication error correction, health care providers must be in agreement about which errors count (ie, near misses or errors that cause patient harm), how to define practice standards to prevent these errors, and how to alter perceptions and biases to improve medication safety.

References

  1. Institute of Medicine. in: L.T. Kohn, J.M. Corrigan, M.S. Donaldson (Eds.) To Err Is Human: Building a Safer Health System. National Academy Press, Washington, DC; 2000
  2. Makary, M.A. and Daniel, M. Medical error—the third leading cause of death in the US. BMJ. 2016;353: i2139
  3. Sentinel event statistics as of: September 30, 2010. The Joint Commission. Published November 23, 2010. Accessed August 30, 2016.
  4. Sentinel event statistics released for 2014. Joint Commission Online. Published April 29, 2015. Accessed August 30, 2016.
  5. Macdonald, M. Patient safety: examining the adequacy of the 5 rights of medication administration.Clin Nurse Spec. 2010; 24: 196–201
  6. Edwards, S. and Axe, S. The 10 ‘Rs’ of safe multidisciplinary drug administration. Nurse Prescr. 2015;13: 398–406
  7. Federico F. Improvement stories: the five rights of medication administration. Institute for Healthcare Improvement. Accessed August 30, 2016.
  8. Patient safety primer: medication errors. Agency for Healthcare Research and Quality. Updated March 2015. Accessed August 30, 2016.
  9. How-to Guide: Prevent Harm From High-Alert Medications. Institute for Healthcare Improvement,Cambridge, MA; 2012
  10. Perception. Merriam-Webster. Accessed August 30, 2016.
  11. Bias. Merriam-Webster. Accessed August 30, 2016.
  12. Banja, J. The normalization of deviance in healthcare delivery. Bus Horiz. 2010; 53: 139
  13. Treiber, L.A. and Jones, J.H. Medication errors, routines, and differences between perioperative and non-perioperative nurses. AORN J. 2012; 96: 285–294

Biography

Desiree D. Redman, BSN, RN, CNOR, is a clinical nurse III in the OR at UNC Health Care, Chapel Hill, NC. Ms Redman has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

 

Source: AORN Journal

 

 

Reducing Medication Errors in the OR

 
 
About The Operating Theatre Journal

The Operating Theatre Journal, OTJ, is published monthly and distributed to every hospital operating theatre department in the UK. The distribution includes both the National Health Service and the Private Sector.

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