Examining medication errors in outpatient surgery—focus on adult population

AORN Journal,  Oct, 2007  

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The United States Pharmacopeia (USP) Center for the Advancement of Patient Safety recently published its seventh report to the nation on medication errors reported to MEDMARX. This year's report, entitled MEDMARX[R] Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005, (1) provides analyses of 7 years of medication errors across the perioperative continuum--outpatient surgery, preoperative holding area, operating room, and the postanesthesia care unit. (See http://www.usp.org/products/medMarx/ to obtain a copy of the full report).

This [article] focuses on one portion of the recently released MEDMARX Data Report--medication errors occurring in the outpatient surgery environment involving adult patients.

BACKGROUND INFORMATION RELATED TO THE OUTPATIENT SURGERY DEPARTMENT

In 1980, Congress changed the Medicare reimbursement policies to favor ambulatory surgery clinics and the provision of patient care in non-inpatient settings. (2) These policies, along with innovations in surgical technology, improved anesthesia and pain management, and increased pressure to control costs through shortened hospital stays, have caused the volume of procedures performed in ambulatory settings to grow steadily; more than three-quarters of all medical procedures are now performed as outpatient surgeries. (3)

The Outpatient Surgery (OPS) department is a specialized setting within a hospital that focuses on the patient's registration and preprocedural/ preoperative screening processes. For MEDMARX reporters, "Outpatient Surgery" is synonymous with same-day surgery, day surgery, or ambulatory surgery centers associated with acute care facilities; and it designates the clinical location where the error originates. The current report does not examine outpatient errors from freestanding surgical centers, nor does it examine errors originating in endoscopy/ GI (gastroenterology) labs; those areas would fall under Endoscopy/GI Laboratory as the location of the error.

SEVERITY AND ORIGIN OF MEDICATION ERRORS REPORTED IN ADULTS (AGES 17-64) RECEIVING CARE IN OUTPATIENT SURGERY (OPS)

Between September 1, 1998, and August 31, 2005, a total of 422 facilities reported errors in OPS to MEDMARX. Collectively, these facilities submitted 3,427 records, of which 2.9% (n = 99) were reported as harmful. There were no reports of either permanent harm or death (Category G or Category I). Of the 3,427 records, 1,081 cases involved adult patients. As a percentage, more harmful errors (Categories E-I) were seen in 5% of medication errors in adult patients, with temporary harm (Category E) comprising a majority of cases that resulted in harmful outcomes.

Based on the number of actual medication errors (Categories B-I; n = 3,138), the largest percentage of all OPS errors (49.8%) originated in the Administering node (phase) of the medication use process. For adult patients, however, nearly 70% of the errors originated during drug administration activities while only 11.7% originated in prescribing. These differences indicate that errors that originate in the Prescribing phase are often intercepted before reaching the patient. Errors originating in the Dispensing phase were present in less than 9% of the events reported.

Errors occurring during the Administering phase may result from the fact that many OPS drugs are not being prepared or reviewed by the pharmacy; rather they are prepared by a nurse on the unit, which bypasses an important safety check. Computerized prescriber order entry (CPOE) technology has been effective in reducing errors (4) in the inpatient setting and in integrated outpatient settings. The OPS setting may present a challenge to fully recognizing the potential of CPOE, given that physicians often see outpatients in a private setting that may not be connected to the hospital's CPOE system. Further, some patients may arrive just prior to the scheduled procedure, and their histories may not be immediately available for review. Together, these common issues in outpatient care hinder the ability of the technology to work effectively in this environment.

TYPES OF MEDICATION ERRORS

Four types of errors (ie, Omission error, Unauthorized/wrong drug, Improper dose/ quantity, Wrong time) comprised 75% of all errors in the adult population (Table 1). Other studies have also shown that errors most of-ten involve an Improper dose/quantity (wrong amount) or an Omission. (5,6) Omitting preprocedural antimicrobial products has been linked to surgical site infections. (7) In the adult population, the proportion of errors associated with harm was 5%; six types of errors exceeded this threshold. Wrong dosage form and Prescribing error were the two types with the highest percentage of harmful events (14.3% and 10.5% respectively).

CASE EXAMPLES:

1. A nurse gave a dose of cefazolin to the wrong adult patient while preparing the patient for surgery. The patient did not have an ID bracelet on, but verbalized an allergy to penicillin. Observation was initiated/increased.