R E V I E W S & A N A LY S E S Ambulatory Surgery Facilities: A Comprehensive Review of Medication Error Reports in Pennsylvania INTRODUCTION Matthew Grissinger, RPh, FISMP, FASCP According to the Pennsylvania Department of Health Bureau of Health Statistics and Senior Patient Safety Analyst Research, the Commonwealth had licensed 265 ambulatory surgery facilities (ASFs), Rabih Dabliz, PharmD, FISMP which performed more than 960,000 procedures between July 1, 2008, and June 30, Patient Safety Analyst 2009.1 ASFs offer services including general surgical, orthopedic, gynecological, uro- Pennsylvania Patient Safety Authority logic, eye, and endoscopic (e.g., colonoscopies, upper gastrointestinal endoscopies) procedures. These were performed by more than 7,000 medical staff with clinical privileges, most commonly in anesthesiology, ophthalmology, and orthopedic surgery. Despite the variety of services provided by ASFs, the types of medications used are ABSTRACT usually limited to antibiotics and intravenous (IV) fluids, as well as many high-alert medications such as analgesics, sedatives, local and general anesthetics, and paralytics. Pennsylvania ambulatory surgery facilities (ASFs) submitted 502 medica- The National Quality Forum (NQF) recently approved for endorsement a list of 29 seri- tion error reports to the Pennsylvania ous reportable events (SREs) in healthcare, outlined in the forthcoming report, Serious Patient Safety Authority from June 28, Reportable Events in Healthcare—2011 Update: A Consensus Report. As a part of this 2004, through December 31, 2010. update to the original SREs in 2002, NQF has added three new care settings, including The most common types of medication ambulatory surgery centers.2 errors reported by ASFs to the Authority There is little in the literature that quantitatively addresses medication errors occurring included drug omission, wrong drug, in ambulatory surgical settings, although a 2005 MedMarx report from the United and monitoring error/documented States Pharmacopeia specifically addresses the outpatient surgery setting.3 Therefore, allergy. The predominant routes of this article analyzes events reported to the Pennsylvania Patient Safety Authority to administration associated with wrong- determine the most common types of events, patient populations involved, and medi- drug errors were intravenous (IV) and cations involved, as well as to comprehensively review event descriptions in reports to ophthalmic. More than one-third of IV determine specific and common issues affecting ASFs. wrong-drug errors involved high-alert medications. Unlike previously reported MEDICATION ERRORS IN PENNSYLVANIA ASFs confusion between eye drops of similar pharmacologic categories, three- Pennsylvania ASFs submitted 502 medication error reports to the Authority from quarters of wrong-drug errors involving June 28, 2004, through December 31, 2010. Categorization of the reports by harm ophthalmic products were mix-ups score, which is adapted from the National Coordinating Council for Medication Error between eye drops of different pharma- Reporting and Prevention harm index,4 shows that 91% (n = 457) of the events reached cologic categories. Strategies to prevent the patient (harm index = C to I). ASFs reported that 3.6% (n = 18) of the events wrong-drug errors, especially for high- resulted in patient harm (harm index = E to I), which is significantly higher than the alert medications in the perioperative overall rate for all medication error reports from reporting acute care facilities (0.6%). area, can be prioritized to prevent harm The 2005 MedMarx report showed that almost 3% of reported errors resulted in harm, to patients undergoing procedures in and three events required life-sustaining interventions to preclude death.3 ASFs, such as requiring labels on all Department of Health data shows treatment at ASFs by population as follows: 57.6% medications, medication containers adults (ages 18 to 64), 37.7% elderly (65 or older), and 4.7% pediatrics (younger than (e.g., syringes, medicine cups, basins), 18).1 Nearly half of the events reported to the Authority, 49% (n = 246), involved the or other solutions on and off the sterile adult population, while 40.2% (n = 202) involved the elderly. Almost 11% (n = 54) of field; differentiating look-alike products reports involved the pediatric population, more than double the percentage treated by highlighting distinguishing informa- in ASFs. tion on the label; and purchasing eye The medications mentioned in reports are representative of the variety of services provided drops within a class from different man- by ASFs. The most common routes of administration reported were IV (46%, n = 231), ufacturers. (Pa Patient Saf Advis 2011 ophthalmic (23.9%, n = 120), and oral (14.1%, n = 71). The most common classes of Sep;8[2]:85-93.) medications (see Table 1) were antibiotics (33.9%, n = 170), local anesthetics (8%, n = 40), and corticosteroids (4.6%, n = 23), while the most common specific medications listed were ceFAZolin (15.3%, n = 77), vancomycin (4%, n = 20), and midazolam (4%, n = 20). Multiple products (e.g., the combination of fentaNYL and midazolam) were also reported (5%, n = 25). The 2005 MedMarx report found that the most common medications Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 85 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 1. Predominant Classes of Medications Mentioned in Events in Ambulatory Surgical (40.2%, n = 45) products. Based on the Facilities, June 28, 2004, through December 31, 2010 (296 of 502 events) description of the events, it appears that % OF TOTAL REPORTS most of the wrong-drugs errors involved MEDICATION NUMBER (N = 502) choosing the wrong product (86.6%, n = 97) with no contributing factors Antibiotics 170 33.9% mentioned. Local anesthetics* 40 8.0 When looking solely at the wrong-drug Corticosteroids 23 4.6 errors involving IV medications, 37.8% Opioid analgesic combinations* 23 4.6 (n = 17) involved high-alert medications such as fentaNYL, EPINEPHrine, ket- Benzodiazepines* 21 4.2 amine, meperidine, and morphine. Nonsteroidal anti-inflammatory agents (NSAIDS) 19 3.8 Anesthesia signs out a drug box each morning. The drug box contains * High-alert medication fentaNYL 200 mcg/2 mL (10 vials), midazolam 2 mg/2 mL (10 vials), and ketamine 500 mg/5 mL (2 vials). involved in errors were ceFAZolin (14.7%, stage (17.9%, n =24), according to events The ketamine was recently added to n = 488), midazolam (3%, n = 100), and reported to the Authority. Overall, anti- the drug box. The doctor stated he was morphine (2.9%, n = 96).3 biotics were the most common class of not aware that ketamine was in the medications omitted (53.7%, n = 72), box. He drew up the ketamine and Drug Omission Errors with ceFAZolin the most commonly administered it as if it were fentaNYL. Surgical site infections (SSIs) are a major omitted within that class (70% of all anti- He labeled the syringe “Fentanyl.” contributor to patient injury, mortality, biotics, n = 35). Benzodiazepines were the The patient was not arousing in the and healthcare costs. Despite evidence of second most frequently omitted class of recovery area as anticipated and the effectiveness of antimicrobials to prevent medications (6%, n = 8), with midazolam doctor was informed of this. The error SSIs, studies have demonstrated inap- accounting for 87.5% (n = 7) of the omit- was realized when the drug box was propriate timing, selection, and excess ted benzodiazepines. checked back in by two staff nurses; duration of administration of antimicro- Review of the drug omission event details the fentaNYL and the ketamine bial prophylaxis. Omitting preprocedural found that 91% (n = 122) of the events counts were incorrect. antimicrobial products has been linked involved a breakdown in the commu- to surgical site infections.5 Antimicro- A nurse was asked to obtain nication of orders or overlooking the bial prophylaxis, such as ceFAZolin, EPINEPHrine 1:10,000 and could preoperative orders. initiated before a procedure reduces sur- not locate the drug in the room. [An elderly] patient was admitted for The nurse left the room to procure gical wound infections, especially when [a procedure]. The admitting nurse the medication. Upon opening the administered within one hour before the transcribed the preoperative orders. medication cabinet, she obtained a surgical incision. The physician prescribed a preopera- vial that was thought to be labeled A national, retrospective, cohort study tive antibiotic (ceFAZolin) after the as “1:10,000.” The medication was with medical record review that measured orders were transcribed by the nurse. mixed with normal saline and admin- the proportion of patients who had par- There was no verbal notification to istered to the patient. After the patient enteral antimicrobial prophylaxis initiated the nurse. The PACU [postanesthesia left the room, the nurse manager was within one hour before the surgical inci- care unit] nurse discovered that the in the room assisting the staff to look sion showed that an antimicrobial order was not given. [The nurse] noti- for EPINEPHrine in the medication dose was administered to only 55.7% fied the physician and the medication drawer. The nurse manager noted that of patients.6 was given in the PACU. heparin vials were inadvertently placed When looking at the stages of the medi- in the drawer and brought this to the cation use process for a procedure in an Wrong-Drug Errors nurse’s attention. The nurse looked in ASF, drug omissions most commonly The routes of administration for medications the sharps box and discovered that she took place during the preoperative stage associated with wrong-drug errors primarily had handed the scrub nurse heparin (60.4%, n = 81) and the postoperative involved ophthalmic (42%, n = 47) and IV instead of EPINEPHrine. Page 86 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority Decadron® 4 mg was prepared in a the risk for confusion, staff relied on of these products later agreed to this.11 syringe to give to patient. A syringe of location in the sterile field to identify For example, the caps and carton labels fentaNYL was at the bedside from a the substances. This time, ethyl alcohol for anti-infective ophthalmic medications previous pain medication injection. was mistakenly drawn into a syringe and are tan. Mydriatics and cycloplegics are Both syringes were labeled as to the injected into the patient’s face instead coded red, miotics are green, beta-blockers contents. FentaNYL was given in of lidocaine. The patient suffered from are yellow or blue, and so forth. The error (meant to give Decadron). The partial facial paralysis and unknown proponents of the color-coding system error was realized as soon as the long-term consequences.7 In 2006, The argue it helps ophthalmologists and meds were given when the nurse saw Joint Commission established a National patients quickly differentiate medica- “fentanyl” on the syringe. The physi- Patient Safety Goal that required organiza- tions. Although it is intended to be an cian was immediately notified and tions to label all medications, medication actual color-code system as defined above, Narcan® was given. containers (e.g., syringes, medicine cups, in reality it is more likely that practi- An at-risk behavior that contributes to basins), and other solutions on and off tioners use the colors to differentiate wrong-drug medication errors in the peri- the sterile field in perioperative and proce- products rather than to identify products operative setting involves the failure to dural areas.10 by pharmacologic class. However, this label stainless steel bowls that hold medi- Similar events reported to the Authority color-coding system may contribute to cations before they are drawn up into a include the following: errors if healthcare practitioners confuse syringe and injected into the patient. Data similar-appearing products in the same During fracture nasal procedure, the class. Color-coding may work well in an from the 2004 Institute for Safe Medica- surgeon requested bupivacaine 0.25% tion Practices (ISMP) Medication Safety office setting or in the patient’s home, but with EPINEPHrine. The surgical when similar corporate logos, fonts, and Self -Assessment® for Hospitals indicated technician drew up the medication that only 41% of hospitals always labeled package sizes are factored in (see Figure), from the OR table into a syringe. color-coding may not be safe in pharma- medications and solutions used in oper- The surgeon administered the medica- ating room (OR) settings.7 An alarming cies, patient care areas, or procedure areas tion intranasally. When preparing where greater numbers of medications are 18% of hospitals did not label containers to soak the Cottonoids® in a [nasal at all, and another 42% applied labels stored.12 Errors have happened when dis- vasoconstrictor] solution, the surgical pensing and administering these products inconsistently. Also in 2004, a 69-year- technician discovered she had only a old Seattle woman died largely because on nursing units, in ophthalmology clin- small amount of [that solution] left ics, and in hospital and ambulatory care of unlabeled basins of solution in the in the medication container. The interventional radiology procedure room. pharmacies.13 The following is an example bupivacaine medication container reported to the Authority: During coil placement under cerebral was still full. The surgeon was noti- angiography to repair a brain aneurysm, fied that the [nasal vasoconstrictor] Preoperatively, the physician pre- the patient was accidentally injected with was possibly administered instead of scribed eye drops for cataract surgery. a topical antiseptic solution, chlorhexi- the bupivacaine as requested and the The bottle of Cyclogyl® 15 mL has dine, instead of contrast media. Both anesthesiologist was notified. Later, a red top. Tropicacyl® has same size solutions were clear and available on the patient was transferred to the criti- bottle and color lid. The Cyclogyl the sterile field in unlabeled basins. The cal care unit at the acute care facility. drops were inadvertently placed into hospital’s decision to switch antiseptics the eye instead of Tropicacyl. from a brown povidone-iodine solution Wrong-Drug Errors Involving Contrary to the previously reported to a clear chlorhexidine solution resulted confusion between eye drops of similar in a latent failure—two look-alike clear Ophthalmic Products There is a long, documented history of pharmacologic categories, 74.5% (n = 35) of solutions previously distinguished by color the wrong-drug errors involving ophthal- on the sterile field. This latent failure confusion between eye drop containers due to similarity in product packaging. mic products submitted to the Authority was revealed when the unlabeled solu- involved mix-ups between eye drops of tion basins were mixed up.8,9 In another In 1996, the American Academy of Ophthalmology urged manufacturers to different pharmacologic categories; 82.9% example, an event was reported to ISMP (n = 29) of these reports specifically men- in which an unlabeled basin contained convert to a uniform color-coding system, based on therapeutic class, for eye solu- tion situations of product selection errors, lidocaine and another unlabeled basin although additional contributing factors contained ethyl alcohol. Although both tions and ointments; the U.S. Food and Drug Administration and manufacturers may have led to the error. solutions were clear, which increased Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 87 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S A patient was scheduled for a YAG Figure. Look-Alike Eye Drop Bottles laser peripheral iridotomy. A nurse administering eye drops was prepar- ing more than one patient for YAG laser procedures at the same time. The nurse did not check the written medication order immediately prior to administering the eye drops and thought the patient was [scheduled] for YAG laser capsulotomy (phenyl- ephrine 2.5% and tropicamide 1%) instead of YAG laser peripheral iridotomy. The nurse accidentally administered the routine eye drops for the capsulotomy procedure. The doctor was notified immediately and the patient was ordered that the left eye should be irrigated and 3 drops of 2% pilocarpine, followed by 1 drop of 2% pilocarpine and 1 drop of 0.5% Iopidine® to left eye in 5 minutes. Proparacaine drops were to be placed Reprinted with permission from the Institute for Safe Medication Practices, Horsham, Pennsylvania. into the operative eye prior to eye prep- aration. Instead, the pilocarpine eye 86 events that described errors involving also had an allergy band on her drop was instilled after surgery. Both documented drug allergies (see Table 2). wrist which was placed by preopera- eye drop bottles were sitting on the eye These 86 events account for 17.1% of all tive staff. The OR nurse confirmed cart. The nurse picked up pilocarpine medication errors reported by ASFs. The the allergy with the patient during instead of proparacaine and did not most common drug classes involved in preoperative questioning. During register the mistake until after the eye these events were antibiotics (46.5%, the procedure, the medication was drop was instilled. Both [bottles] were n = 40), contrast media (8.1%, n = 7), dispensed to the physician by the OR sitting in close proximity of each other and antiseptics (7%, n = 6). nurse and the medication was admin- for the case and both bottles are quite A patient was interviewed prior istered to the patient by the physician. similar looking (but not alike). to the procedure by the circulat- The OR nurse realized the error ing nurse. The patient denied any immediately after the procedure. The Errors Involving Documented allergies when asked, but had a red patient was taken to the PACU and Drug Allergies medication allergy bracelet on. The monitored. She was given Benadryl® bracelet said “powdered gloves,” and and Decadron in the PACU. When reviewing event descriptions for event reports classified as “other” (n = 107), the patient said that she did indeed A surgeon’s postoperative instructions analysts found that 33.6% (n = 36) indi- have an allergy after denying it previ- included “Diamox Sequel® 500 mg cated that a patient received a medication ously. The OR nurse then asked if for one dose” to be administered except to which he or she had a documented the patient had any allergies to beta- in the case if patient was allergic to allergy, similar to what was reported by dine, iodine, or shellfish. The patient sulfa. Patient received a one-time dose the Authority in September 2008.14 In stated “no.” The patient was taken of Diamox 500 mg [a sulfa derivative] addition, a review of the wrong-drug back to the OR and the nurse started and there was documentation indicat- prepping the operative site with beta- ing that patient was allergic to “sulfa” events revealed another 14 events in dine. The patient then stated that drugs. Patient also had an allergy which a patient almost or actually received the nurse should stop because she is bracelet indicating sulfa allergy. After a medication to which he or she had a allergic to the prep. a follow-up phone call to the patient history of allergies. Facilities also reported 36 events with the event type “monitoring Patient had a documented allergy and family, it was found that the error/documented allergy,” for a total of to IV dye on the chart. The patient patient did present with a delayed Page 88 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority Table 2. Predominant Medication Error Event Types Associated with Ambulatory Surgery the organization’s SSI improvement Facilities, June 28, 2004, through December 31, 2010 (453 of 502 events) team determined that the anesthesia % OF TOTAL REPORTS care provider should administer EVENT TYPE NUMBER (N = 502) the antibiotics immediately before the patient leaves the preoperative Drug omission 134 26.7% holding area. This process change Wrong drug 112 22.3 enabled healthcare practitioners to Monitoring error/documented allergy 86 17.1 consistently administer antibiotics within 60 minutes of the initial Extra dose 21 4.2 incision. Wrong dose/overdosage 18 3.6 Wrong dose/underdosage 11 2.2 Wrong-Drug Errors Although there were few reported cases Other 71 14.1 of unlabeled bowls or syringes, organiza- tions should have policies and procedures allergic reaction to the medication that include antibiotic selection for the safe labeling of medications and given (Diamox) in which the patient/ and time of administration. The solutions used on a sterile field. The Joint family reported facial swelling, which electronic chart may include a ques- Commission National Patient Safety Goal is now subsiding. tion asking if antibiotics had been NPSG.03.04.01 mandates such labeling in ordered. both inpatient and outpatient settings and The analysts note that it is the responsibil- requires the following in perioperative ity of the prescriber to check for allergies — Review preoperative standing order and other procedural settings both on and and not write an order to administer a forms for select surgical diagnoses off the sterile field:16 medication “unless the patient is allergic.” to ensure they include preopera- tive antibiotic administration, as — Label medications and solutions that well as the specified antibiotic and are not immediately administered. RISK-REDUCTION STRATEGIES timing for surgical procedures for — Label any medication or solution ASFs can strive to identify system-based which preoperative antibiotics are that is transferred from the original causes of the medication errors that occur recommended. packaging to another container. and implement effective risk-reduction — In the preoperative holding area, — Verify all medication or solution strategies to prevent harm to patients. introduce a process to screen preop- labels both verbally and visually. Veri- Although many of the events reported erative antibiotic orders according to fication is done by two individuals to the Authority were not explicit in national guidelines and immediately qualified to participate in the proce- revealing all the causes and contributing notifying physicians of problems. dure whenever the person preparing factors of drug omissions, wrong–drug Assign responsibility to the preopera- the medication or solution is not the errors, and documented allergies, health- tive holding-area staff for ensuring person who will be administering it. care facilities may consider the strategies that patients have orders for pre- Strategies to improve the labeling of described below, which are based on operative antibiotics. Incorporate medications on a sterile field as well as a review of events reported to the a check by anesthesia and OR staff to prevent wrong-drug errors include the Authority, observations from ISMP, and to verify appropriate preoperative following:17,18 recommendations in the literature. antibiotic therapy has been initiated Provide labels. Make labeling easy by or completed. Antibiotic Omission using sterile markers, blank labels, and — Change the preoperative processes preprinted labels (prepared by the facility Strategies designed to improve com- for antibiotic administration. One or commercially available) that can be pliance with prophylactic antibiotic organization determined the aver- opened onto the sterile field during administration within 60 minutes of ini- age time from when the patient all procedures. tial incision include the following:15 enters the OR to when the initial — Use prompts in the electronic incision was made, which for all Require labels. Require labels on all documentation of perioperative care procedures ranged from 20 to 30 medications, medication containers regarding prophylactic antibiotics minutes. Based on this information, (e.g., syringes, medicine cups, basins), Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 89 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S or other solutions on and off the sterile Perhaps the best way to prevent mix-ups of patient’s allergies when prescribing field, even if only one medication or ophthalmic products is to avoid purchas- medications or transcribing a verbal solution is involved. Also require labels ing all eye drops from one manufacturer order for a medication. on all solutions, chemicals, and reagents and to purchase drugs within a class from — Educate prescribers and nurses about (e.g., formalin, saline, Lugol’s solution, different manufacturers.13 medication allergies. These efforts radiocontrast media) that are used in peri- can include organization-specific pro- operative units. Documented Allergies cedures such as where to document Differentiate look-alike drug names and As mentioned in the September 2008 or find patient allergy information, products. If drug or solution names or Pennsylvania Patient Safety Advisory article, as well as how to access important packaging are similar, use tall man lettering “Medication Errors Associated with Docu- drug information that includes com- (e.g., EPINEPHrine) on the labels to dif- mented Allergies,” specific strategies to mon allergies, cross allergies, and ferentiate them, or highlight or circle the prevent the prescribing and administration multi-ingredient drug products that distinguishing information on the label. of medications to patients with docu- may have implications for common For example, consider purchasing skin mented allergies include the following:14 drug allergies. antiseptic products in prepackaged swabs — Review all paper and online data — Use information published by the or sponges to clearly differentiate them collection forms to determine the Authority to identify problem areas, from medications or other solutions and current location in which practi- processes, or medications and to eliminate the risk of accidental injection. tioners will document and retrieve determine the types of events that Confirm medications and labels. Require complete allergy information, includ- occur within the facility. the scrub person and the circulating ing descriptions of any reaction — Measure the use of trigger drugs nurse to concurrently verify all medica- (e.g., front of medical record, on top used to treat allergic reactions (e.g., tions and solutions visually and verbally of order forms, computer screens, diphenhydrAMINE, methylPRED- by reading the product name, strength, assessment forms). This location NISolone, EPINEPHrine) to increase and dosage from the labels. (If there is no can be standardized and used by detection of possible preventable scrub person, the circulating nurse can all staff in the facility. Alert staff to adverse drug events and determine verify the medication or solution with always refer to these areas for reliable whether patients with documented the licensed professional performing the information. allergies are erroneously receiving procedure.) When passing a medication to — Consider adding prompts in consis- medications. Collection of trigger the licensed professional performing the tent locations to document allergy data could be incorporated into procedure, visually and verbally verify the information, and include clearly vis- the order-screening processes or medication, strength, and dose by reading ible and prominently placed allergy accomplished by those who routinely the label aloud. The healthcare practitio- prompts at the top of every page review patient records, such as qual- ner administering the medication also can of all prescriber order forms (includ- ity managers or case managers. read the product label to verify that it is ing blank, preprinted, and verbal the correct medication. order forms). CONCLUSION Standardize medications. Standardize — On a patient’s admission to the In Pennsylvania ASFs, 502 medication and limit the variety of strengths and facility, list allergies, describe the errors have been reported. The predomi- concentrations of medications as much reaction to the allergen, and, if nant types of medication errors are drug as possible. Communicate any changes in possible, record the date that the omissions, wrong-drug errors with IV available strengths and concentrations to reaction took place on all admission and ophthalmic products, and prescrib- front-line staff. forms. Have appropriate staff con- ing and administering of medications to sistently transfer this information patients with documented allergies. Use Storage of medications. Store medications of strategies to prevent wrong drug errors, to subsequent forms and place the safely with consideration given to separate especially with high-alert medications in completed forms into the charts so look-alike products. This includes separat- the perioperative area, can help prevent that they are readily accessible. This ing by generic name and packaging to the harm to patients undergoing procedures process can help visually remind extent possible. in ASFs. physicians and nurses about the Page 90 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority NOTES 1. Pennsylvania Department of Health 6. Bratzler DW, Houck PM, Richards C, 13. Institute for Safe Medication Practices. Bureau of Health Statistics and Research. et al. Use of antimicrobial prophylaxis for Caution regarding color-coded eye meds. Data from the annual ambulatory surgery major surgery: baseline results from the ISMP Med Saf Alert 2008 Apr 24;13(8):1-2. center questionnaire [report online]. 2010 National Surgical Infection Prevention 14. Medication errors associated with docu- Mar 1 [cited 2011 Apr 11]. Available Project. Arch Surg 2005 Feb;140(2):174-82. mented allergies. Pa Patient Saf Advis from Internet: http://www.portal.state. 7. Institute for Safe Medication Practices [online] 2008 Sep [cited 2011 Apr 12]. pa.us/portal/server.pt?open=space&name (ISMP). Worth repeating: drug product Available from Internet: http://www. =Dir&psname=SearchResult&psid=4& confusion in sterile field. ISMP Med Saf patientsafetyauthority.org/ADVISORIES/ cached=true&in_hi_userid=2&control= Alert 2005 Mar 10;10(5):3. AdvisoryLibrary/2008/Sep5(3)/Pages/ OpenSubFolder&subfolderID=153980& 8. Institute for Safe Medication Practices 75.aspx. DirMode=1. (ISMP). Loud wake-up call: unlabeled 15. White A, Schneider T. Improving com- 2. National Quality Forum. NQF releases containers lead to patient’s death. ISMP pliance with prophylactic antibiotic updated serious reportable events [online]. Med Saf Alert 2004 Dec 2;9(24):1-2. administration guidelines. AORN J 2007 [cited 2011 Jun 20]. Available from 9. Ostrom CM. Settlement to be used for Jan;85(1):173-80. Internet: http://qualityforum.org/News_ hospital training in labeling medicines 16. Joint Commission. National patient safety And_Resources/Press_Releases/2011/ [online]. Seattle Times 2005 Sep 13 [cited goals [online]. 2010 [cited 2011 Apr 13]. NQF_Releases_Updated_Serious_ 2011 Apr 15]. Available from Internet: Available from Internet: http://www. Reportable_Events.aspx. http://seattletimes.nwsource.com/ jointcommission.org/assets/1/6/ 3. Hicks RW, Becker SC, Cousins DD. html/localnews/2002490718_ 2011_NPSGs_HAP.pdf. MEDMARX® data report: a chartbook mcclinton13m.html. 17. Smezter JL, Cohen MR. Preventing drug of medication error findings from the 10. Institute for Safe Medication Practices administration errors. In: Cohen MR ed. perioperative settings from 1998-2005. (ISMP). AORN national campaign. ISMP Medication errors. 2nd ed. Washington Rockville (MD): USP Center for the Med Saf Alert 2005 Jun 30;10(13):2-3. (DC): American Pharmacists Association; Advancement of Patient Safety; 2006. 11. American Academy of Ophthalmology. 2007:2235-74. 4. National Coordinating Council for Medi- Policy statement: color codes for topical 18. Association of periOperative Registered cation Error Reporting and Prevention. ocular medications [online]. 2010 [cited Nurses. AORN guidance statement: NCC MERP index for categorizing medica- 2011 Apr 13]. Available from Internet: safe medication practices in periop- tion errors [online]. 2001 [cited 2011 Apr http://www.aao.org/about/policy/ erative settings across the life span 11]. Available from Internet: http://www. upload/color-codes-for-topical-ocular- [online]. 2005 [cited 2011 Apr 12]. nccmerp.org/medErrorCatIndex.html. medications-2010.pdf. Available from Internet: http://www. 5. Mangram AJ, Horna TC, Pearson ML, aorn.org/docs/assets/A3303E94- 12. Cohen MR. The role of drug packaging et al. Guideline for prevention of surgical 17A4-49A8-86BD933E43183993/ and labeling in medication errors. In: site infection, 1999. Infect Control Hosp AGS_Safe_Medication_Practices.pdf. Cohen MR ed. Medication errors. 2nd ed. Epidemiol 1999 Apr;20(4):250-80. Washington (DC): American Pharmacists Association; 2007:111-152. Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 91 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recognize the predominant types of The following questions about this article may be useful for internal education and medication errors associated with assessment. You may use the following examples or develop your own questions. ambulatory surgery facilities (ASFs), 1. The most frequently reported type of medication errors occurring according to reports submitted to in ASFs is . the Pennsylvania Patient Safety a. extra dose Authority. b. drug omission — Recall the most common classes of c. wrong drug drugs involved in medication errors d. other in ASFs. e. monitoring error/documented allergy — Identify factors frequently involved 2. All of the following are true about wrong-drug errors in ASFs EXCEPT: in wrong-drug medication errors in ASFs. a. More than 40% of wrong-drug error reports mention ophthalmic products. b. An at-risk behavior that contributes to wrong-drug medication errors in the — Distinguish between effective and perioperative setting involves the failure to label stainless steel bowls that ineffective risk reduction strategies hold medications. for ASF practitioners to promote the safe use of medications. c. High-alert medications were involved in more than 37% of wrong-drug errors involving intravenous products. d. Analysis of Authority reports involving wrong-drug errors found that nearly 90% of reports did not indicate contributing factors. e. More than 74% of wrong-drug error reports involving ophthalmic products involved mix-ups with products of similar pharmacologic categories. 3. All of the following are effective strategies to reduce the risk of wrong-drug medication errors in ASFs EXCEPT: a. Purchase sterile markers, blank labels, and preprinted labels prepared by the facility or commercially available that can be opened onto the sterile field dur- ing all procedures. b. Avoid purchasing all eye drops from one manufacturer, especially drugs within the same pharmacologic class. c. Require labels on all medications, medication containers (e.g., syringes, medi- cine cups, basins), or other solutions on and off the sterile field. d. Verification of medication labels should be done by an individual qualified to participate in the procedure. e. Differentiate look-alike drug names and products by using tall man lettering (e.g., EPINEPHrine) or highlighting or circling the distinguishing information on the label. 4. Which of the following is the predominant class of medications mentioned in medication errors reported by ASFs? a. Opioid analgesic combinations b. Neuromuscular blocking agents c. Corticosteroids d. Antibiotics e. Benzodiazepines Page 92 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority SELF-ASSESSMENT QUESTIONS (CONTINUED) Case Scenario 1 A surgeon’s postoperative instructions included “Diamox Sequel® 500 mg for one dose” to be administered except in the case if patient was allergic to sulfa. Patient received a one-time dose of Diamox 500 mg (a sulfa derivative) and there was documentation indicating that patient was allergic to “sulfa” drugs. Patient also had an allergy bracelet indicating sulfa allergy. After a follow-up phone call to the patient and family, it was found that the patient did present with a delayed allergic reaction to the medication given (Diamox) in which the patient/family reported facial swelling, which is now subsiding. 5. Which of the following strategies would not help prevent the above scenario from occurring? a. Avoid writing an order to administer a medication with a conditional state- ment such as “unless the patient is allergic.” b. Standardize the location where a patient’s complete allergy information, including descriptions of the reaction, appears (e.g., front of medical record, on the top of order forms, computer screens, assessment forms). c. Measure the use of trigger drugs used to treat allergic reactions (e.g., diphen- hydrAMINE, methylPREDNISolone, EPINEPHrine) to increase detection of possible preventable adverse drug events. d. Have appropriate staff consistently transfer allergy information obtained on admission to subsequent forms and place the completed forms into the charts so that they are readily accessible. e. Provide prescribers and nurses access to important drug information that includes common allergies, cross allergies, and combination drug products that may have implications with common drug allergies. Case Scenario 2 An elderly patient was admitted for a procedure. The admitting nurse transcribed the preoperative orders. The physician prescribed a preoperative antibiotic (ceFAZolin) after the orders were transcribed by the nurse. There was no verbal notification to the nurse. The postanesthesia care unit (PACU) nurse discovered that the order was not given. The nurse notified the physician and the medication was given in the PACU. 6. Which of the following strategies would not help prevent the above scenario from occurring? a. Use prompts in the documentation of perioperative care regarding prophylac- tic antibiotics that include antibiotic selection and time of administration. b. Use verbal orders to communicate preoperative antibiotic orders between pre- scribers and nurses. c. Incorporate a check by anesthesia and operating room staff to verify appropri- ate preoperative antibiotic therapy has been initiated and/or completed. d. Review preoperative standing order forms for select surgical diagnoses to include preoperative antibiotic administration as well as the specified antibi- otic and timing for surgical procedures for which preoperative antibiotics were recommended. e. Assign responsibility to the preoperative holding area staff for ensuring that patients have orders for preoperative antibiotics. Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 93 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 3—September 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR Reader to subscribe to receive the Advisory for free.