Perioperative Initiatives for Medication Safety

By Wanzer, Linda J

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 procedurebased 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 soundalike 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. Perioperativespecific 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.

DISTRACTIONS

Distractions have been identified as one of the top contributory causes of medication errors in the OR.6 In the OR environment, no sooner is one activity started than the request for another is given. How can OR personnel handle this chaos? The solution is to implement a donot-enter policy after a procedure starts. The policy may include

* decreasing interruptions for the individuals in the room,

* leaving all beepers at the front desk,

* delegating an individual at the front desk to answer all calls and take messages, or

* having the surgeon hand off the beeper in advance to another individual to handle business until surgery is completed.

Many institutions are implementing preprocedure surgical briefs, time outs, or huddles. Whatever the name, the concept remains the same-getting the whole team on the same page. The team gathers before the procedure to discuss key information. This gathering can include a brief discussion of intraoperative medications, specifically identifying the type of medication, medication dose, toxic dose limits, and patient allergies.

STANDARDIZE INSTITUTIONAL FORMS

A basic but often timeand labor-intensive process is standardizing institutional forms. This initiative could provide positive benefits for an organization in its fight against medication errors. The very act of form standardization could help improve communication and decrease confusion among health care team members. Examples of standardization might include standardizing patient identification stamp placement so team members consistently look in one place for the information on all forms and documenting patient weight information in both pounds and kilograms to decrease confusion and facilitate discrepancy identification.

LACK OF KNOWLEDGE

Knowledge deficit is another cause of medication errors in the OR.6 Is medication competency testing a part of the hospital orientation? If so, is the test specific to the perioperative environment? Typically, if an institution has a medication test it is a generic, “one size fits all” test that falls short of validating medication knowledge within the perioperative setting. Perioperative staff members are involved with medications that other areas do not use and vice versa. Develop a medication competency test that specifically highlights high risk medications; toxic dose calculations; allergies, contraindications, and substitutions; and nonpunitive error reporting processes for the OR.

KNOWLEDGE IS POWER

Arming perioperative staff members with knowledge will help them avoid medication errors and allow them to be proponents of patient safety as they strive to uphold the medical tenet “above all, do no harm.”8 AORN has developed a Safe Medication Administration Tool Kit designed to assist the perioperative community in its battle to prevent medication errors.9 The Safe Medication Administration Tool Kit is available at http://www.aorn.org/toolkit /safemed/.

Editor’s notes: The views expressed are those of the author and do not necessarily reflect those of the Uniformed Services University, Department of Defense, or the US Government.

MEDMARX is a registered trademark of United States Pharmacopeia, Rockville, Md.

Separating sound-alike and look-alike medications from each other will decrease the risk of choosing the wrong medication.

Many institutions are implementing preprocedure surgical briefs, time outs, or huddles. These processes put the whole team on the same page.

Arming perioperative staff members with knowledge will help prevent medication errors and allow them to uphold the medical tenet “above all, do no harm.”

NOTES

1. “Facts about 2006 National Patient Safety Goals,” Joint Commission on Accreditation of Healthcare Organizations, http:// www.jcaho.org/accredited+or ganizations/patient+safety/06_nps g/06 _facts.htm (accessed 5 July 2005).

2. C A Ziter, B W Dennis, L K Shoup, “Justification of an operating room satellite pharmacy,” American Journal of Hospital Pharmacy 46 (July 1989)13531361.

3. “Making health care safer: A critical analysis of patient safety practices,” Agency for Healthcare Research and Quality, http:/ /www.ahrq.gov/clinic/ptsafety (accessed 24 Aug 2005).

4. “Joint Commission 2006 National Patient Safety Goals implementation expectation,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/accred ited+organizations/patient+safe ty/06_npsg_ie.pdf (accessed 5 July 2005).

5. R W Hicks, D D Cousins, R L Williams, Summary of Information Submitted to MEDMARX in the Year 2002: The Quest for Quality (Rockville, Md: United States Pharmacopeia Center for the Advancement of Patient Safety, 2003).

6. R W Hicks, D D Cousins, R L Williams, MEDMAKX 5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends, 1999-2003 (Rockville, Md: United States Pharmacopeia Center for the Advancement of Patient Safety, 2004).

7. “Safe medication practices in perioperative practice settings,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 196-198.

8. J Chadwich, W N Mann, “Oath of Hippocrates,” University of Michigan Medical School, http://www.med.umich.edu/irbmed /ethics/ hippocratic/hippocratic.html (accessed 5 July 2005).

9. “AORN’s Safe Medication Administration Tool Kit,” AORN http:// urww.aorn.org/toolkit/safe meal (accessed 5 July 2005).

LINDA J. WANZER

RN, MSN, CNOR, COL, AN, USA

PROGRAM DIRECTOR

UNIFORMED UNIVERSITY OF THE HEALTH SCIENCES

BETHESDA, MD

Copyright Association of Operating Room Nurses, Inc. Oct 2005