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Medication Errors in Ambulatory Surgery Facilities
Matthew C. Grissinger, RPh, FISMP, FASCP
Director, Error Reporting Programs
Institute for Safe Medication Practices (ISMP)
Clinical Analyst
Pennsylvania Patient Safety Authority
© 2015 Pennsylvania Patient Safety Authority
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Objectives
1. Discuss the types of medication events that are
reported in Pennsylvania ambulatory surgery settings.
2. Identify system-based causes of medication errors associated with the use of medications in the perioperative setting.
3. Prioritize selected strategies to prevent harm and improve medication safety in the surgical setting.
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Medication Errors Reported by ASFs
• ASFs submitted 502 medication error reports to the Pennsylvania Patient Safety Authority from June 29, 2004, through December 31, 2010.
• Categorization of the reports by harm score shows that – 91% (n = 457) of the events reached the patient
(harm index = C to I) and
– 3.6% (n = 18) of the events resulted in patient harm (harm index = E to I).
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Medication Errors and Population
• Age groups treated in PA include; – Adult population between 18 - 64 years of age (n = 57.6%),
– Elderly 65 years of age and above (n = 37.7%),
– Pediatrics patients less than 18 years of age (n = 4.74%).
• Events reported to the Authority, – 49% (n = 246), involved the adult population
– 40.2% (n = 202) involved the elderly
– 10.8% (n = 54) involved the pediatric population
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Common Event Types Predominant Medication Error Event Types Associated with Ambulatory Surgery Centers, June 30, 2004, through December 31, 2010
EVENT TYPE NUMBER % OF TOTAL REPORTS
(N = 502)
Drug Omission 134 26.7%
Wrong Drug 126 25.1%
Other 107 21.3%
Monitoring error/documented allergy 36 7.17%
Extra dose 21 4.2%
Wrong dose/over dosage 18 3.6%
Wrong dose/under dosage 11 2.2%
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Common Routes and Medications • Most common routes of administration listed were
– Intravenous (IV) (46%, n = 231)
– Ophthalmic (23.9%, n = 120)
– Oral (14.1%, n = 71)
• Most common classes of medications were
– Antibiotics (33.9%, n = 170)
– Local anesthetics (8%, n = 40)
– Corticosteroids (4.6%, n = 23)
• Most common specific medications listed were
– ceFAZolin (15.3%, n = 77)
– vancomycin (4%, n = 20)
– midazolam (4%, n = 20)
– Multiple products (e.g., the combination of fentaNYL and midazolam) were also reported (5%, n = 25)
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Drug Omission • Drug omissions most commonly took place in the pre-operative
stage (60.5%, n = 81) followed by the post-operative stage (17.9%, n =24).
• Overall, antibiotics were the most common class of medications omitted (61.7%, n = 50) with ceFAZolin the most commonly omitted within that class (70% of all antibiotics, n = 35).
– Benzodiazepines were second most frequently omitted class of medications (9.9%, n = 8,) and midazolam accounted for 87.5% (n = 7) of the omitted benzodiazepines.
• Review of the drug omission event details found that 91 % (n = 122) of the events involved situations in which a breakdown in the communication of orders occurred or the pre-op orders being simply overlooked.
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Wrong Drug Errors • Routes of administration for medications
associated with wrong drug errors primarily involved ophthalmic (37.3%, n = 47) and IV (35.7%, n = 45) products. – Differs from all medication errors – IV [46%, n = 231], ophthalmic [23.9%, n = 120], and oral [14.1%, n =
71].
• Most of the wrong drug errors involved choosing the wrong product (77%, n = 97) with no contributing factors identified (e.g., look-alike packaging, drugs stored next to each other).
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Wrong Drug Errors • When looking at the wrong drug errors involving IV
medications, 37.8% (n = 17) involved high-alert medications such as
– fentaNYL,
– EPInePHRINE,
– ketamine,
– morphine.
• One at-risk behavior that contributes to wrong drug medication errors involves the failure to label stainless steel bowels or syringes.
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Wrong Drug Errors with Ophthalmic Products
• Contrary to the previously reported confusion, 74.5% (n = 35) of the wrong drug errors involving ophthalmic products involved mix-ups between eye drops of different pharmacologic categories.
• 82.9% (n = 29) of these reports specifically mention situations of product selection errors, although there may have been additional contributing factors that led to the error.
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Errors Involving Documented Drug Allergies
• When reviewing reports classified as “Other” (n = 107), 33.6% (n = 36) indicated that a patient received a medication to which the patient had a documented allergy.
• Facilities also submitted 36 reports with the event type “Monitoring error/documented allergy,” for a total of 72 total reports (14.3% of all events).
• The most common drug classes involved in these events were antibiotics (40.3%, n = 29), contrast media (9.7%, n = 7) and antiseptics (8.3%, n = 6).
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Documented Allergy Example • Patient had a documented allergy to intravenous (IV)
dye on the chart.
• The patient also had an allergy band on her wrist which was placed by pre-op staff.
• The OR nurse confirmed the allergy with the patient during preoperative questioning.
• During the procedure, the medication was dispensed to the physician by the OR nurse and the medication was administered to the patient by the physician.
• The OR nurse realized the error immediately after the procedure.
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Evaluation of Perioperative Medication Errors and Adverse Drug Events
• A two-pronged approach was used to capture suspected MEs and/or ADEs: direct observation and chart review.
• A total of 277 operations were observed with 3,671 medication administrations of which 193 involved a ME and/or ADE.
• Of these, 153 (79.3%) were preventable and 40 (20.7%) were nonpreventable.
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Evaluation of Perioperative Medication Errors and Adverse Drug Events. Nanji KC, Patel A, Shaikh S et al. Anesthesiology 2015; XXX:00-00 http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2466532&resultClick=3
Evaluation of Perioperative Medication Errors and Adverse Drug Events
• Of the 153 errors, 99 (64.7%) were serious, 51 (33.3%) were significant, and 3 (2.0%) were life-threatening.
• 1 in 20 perioperative medication administrations, and every second operation, resulted in a medication error and/or an adverse drug event
• More than one third of these errors led to observed patient harm, and the remaining two thirds had the potential for patient harm
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Evaluation of Perioperative Medication Errors and Adverse Drug Events. Nanji KC, Patel A, Shaikh S et al. Anesthesiology 2015; XXX:00-00 http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2466532&resultClick=3
Evaluation of Perioperative Medication Errors and Adverse Drug Events
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Evaluation of Perioperative Medication Errors and Adverse Drug Events. Nanji KC, Patel A, Shaikh S et al. Anesthesiology 2015; XXX:00-00 http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2466532&resultClick=3
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Identification of System Flaws
• Direct observation
• Chart review
• Event reporting
Likelihood
of
Success
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Direct Observation
Benefits Disadvantages
• Medication safety-focused perspective to identify greater variety of latent systems failures and process issues
• Time consuming
• Relationship development with perioperative staff and providers
• Hawthorne effect?
• Greater workflow understanding for consideration of process changes
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Medication Storage
• Anesthesia carts
• OR case kits
• Narcotic exchange kits
• OR automated dispensing cabinets (ADCs)
• Anesthesia storage room
• OR pharmacy satellite
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Drug Storage
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How are drugs being stored?
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Anesthesia Medication Cart
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CDC Safe Injection Practices • “Do not administer medications from single-dose vials or
ampules to multiple patients”
• “Do not use bags or bottles of IV solution as a common source of supply for multiple patients”
• “Do not keep multi-dose vials in the immediate patient treatment area (room, bay, suite)”
• “Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's IV infusion bag or administration set”
• Pre-spiking IV bags
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Drug Kits • Multiple varieties and titles
• Many created spontaneously by department
• Pharmacy may not be aware
• Contain excessive types and quantities of drugs
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Narcotic Exchange Kit
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Chemotherapy Surprise?
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Drug Storage and Standardization
• Often find “catch-all” shelves, boxes, drawers
‒ If a drug was requested once, it gets included in the drawer “just in case”
‒ Concentrated electrolytes (used for cardioplegia)
‒ No specific location for the drug to be stored
‒ Just placed (stashed?) randomly
‒ No inventory control mechanism for replacement
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Drug Information
• Inaccessible or outdated drug information references
– Surgeon preference cards
– Emergency drug reference cards/charts • Malignant hyperthermia, lipid infusions
– Broselow tape/drug references on pediatric and adult crash carts
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HAL, are you there?
• Lack of integration of OR computer system with EHR – resulting in:
‒ Inaccurate/different patient information ‒ Allergies, drugs administered
‒ Lack of similar decision support, safeguards, forcing functions
‒ Lack of barcode medication administration (BCMA) system, smart pumps
‒ Resume orders, range orders, titration orders
‒ Lack of pharmacist order review
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Communication of Medication Orders
• Surgeon Preference Cards
– Equipment, instruments, supplies and medications
• Physician-specific, based on surgical procedure
– Handwritten entries
– Procedural preference card applications
– Often difficult to keep updated
– Oversight of approval and review process
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Communication of Medication Orders
• Verbal Orders
– Fast paced environment
– Muffled speech
– Rotating medical team members
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Medication Verification
• Validation against the medication order
• Communication between circulator and scrub nurse/technician
– During medication transfer on and the off field
– Labeling of medication containers
– When relief staff arrive
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Label? Label what?
• Labeling of BUD on MDVs
• Labeling of IV lines
• Labeling on the sterile field
‒ Pre-labeling of containers
‒ Unreadable handwritten labels
‒ No strength or wrong strength on label
‒ Lack of verbal and visual identification
‒ Failing to label ‒ “it’s the only milky white drug we use”
‒ Neuraxial blocks
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Labeling
• On and off the sterile field
• Syringes, basins, cups
• One at a time
• Medication containers saved
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Drug Labeling
Is this the proper way?
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More Drug Labeling Issues
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Anesthesia Syringes
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Environment
• Poor culture of safety – disruptive behavior
• Distractions when drawing up medications
‒ Music in OR suite too loud
‒ Lighting poor when scopes in use
• Staff training in medication use lacking
‒ Especially opioids
• Inadequate monitoring – alarm fatigue
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Strategies for Wrong Drug Errors • Standardize and limit variety of strengths and
concentrations of drugs
• Purchase products from different companies
• Separate look-alike products
• Differentiate similar products
• Provide and require labels
• Confirm medications and labels
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Strategies for Allergies
• Standardize locations of allergy information
• Include the reactions!!!
• Add prompts in consistent locations to document allergies and reactions
• Use triggers to measure incidence of preventable allergic reactions
– Diphenhydramine
– IV steroids
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Perform a Risk Assessment
• Does your department:
‒ Get medications, fluids or contrast agents from outside vendors, hospital purchasing, or pharmacy
‒ Require the same medication administration competency and policies as other procedures/surgeries
‒ Perform sedation procedures and recover patients in the department
‒ Track patient outcomes post procedure
‒ Report errors/near misses
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Process Improvement: Process Flow Mapping
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Wade, E. Practical Approaches to Implementing Medication Safety Strategies in the Perioperative Setting. 49th ASHP Midyear Clinical Meeting. Anaheim, CA. Dec 10, 2014.
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Resources
• Patient Safety Advisory – http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLib
rary/2011/sep8%283%29/Pages/85.aspx
• ISMP Medication Safety Alert! – https://www.ismp.org/newsletters/acutecare/showarticle.aspx?
id=44 – http://www.ismp.org/newsletters/acutecare/showarticle.aspx?i
d=93
• Consensus Statement on Infection Control Measures of Single Dose Vials for Multiple Patients – http://www.ismp.org/docs/newsletter_document_2012-1.pdf
• all photos were reprinted with permission from ISMP
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