USP report details extent of surgery medication errors

From the holding area to the recovery room, drug mistakes in surgery are common and can cost lives. Experts call for more pharmacist involvement.

By Kevin B. O’Reilly — Posted March 26, 2007

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For an outpatient surgical procedure on an elderly female patient, the physician gave a verbal order for 100 mcg fentanyl and 1 mg midazolam. The nurse confirmed the order but incorrectly administered the drugs. After 11 minutes, the patient was unresponsive and a team rushed to save her life with naloxone and supplemental oxygen.

This was just one of more than 11,000 surgical medication errors that 870-plus hospitals reported to U.S. Pharmacopeia's Medmarx database between 1998 and 2005. In this case, the improper dose of fentanyl due to a misunderstood verbal order nearly cost the patient her life. In about 5% of the errors, the wrong drug, wrong dose, wrong time, wrong administration, or omission of drug caused direct harm to the patient and, in four cases, contributed to or directly caused patient deaths.

According to USP's March report, medication errors occur in all the clinical areas involved in perioperative care: outpatient surgery, the holding area, the operating room and the recovery room. Communication errors, failure to follow procedures and protocols, and inadequate documentation were some of the most frequently reported causes of errors.

While nurses were identified the majority of the time as being directly involved with the error, physicians were the second most likely to be so identified. The drugs most frequently involved with errors, though also the most widely used in surgery, were antibiotics and painkillers.

Experts said that because the USP report relies on voluntarily reported data, it is likely to underestimate the extent of medication errors, as well as how frequently they cause harm.

Albert Wu, MD, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health and a member of the Institute of Medicine's drug errors panel, said the report should remind physicians and other health professionals that surgical errors are not the only ones to be concerned about in the perioperative setting.

"We don't have a count of things that went wrong with the procedures themselves in the report," Dr. Wu said, "but it is likely that medication errors were the most common problem -- that is true in almost any given setting."

Diane D. Cousins, vice president of USP's Dept. of Healthcare Quality and Information, said the patient's journey through the different areas results in dangerous mishaps.

"The perioperative setting is a fragmented system that leads to medication errors," Cousins said. "There are numerous errors that lead to overall lapses. There is no single individual or role responsible for tracking medications as the patient is transported through the system."

Among the dozens of recommendations included in the USP report is a call for hospitals to dedicate a pharmacist to the perioperative units to oversee medications and help coordinate better handoffs.

Robert Wachter, MD, chief of the medical service at the University of California, San Francisco Medical Center and author of Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes, said that is a good idea.

"In the OR environment, in particular, people may take their eye off the ball when it comes to medications," Dr. Wachter said. "They are so focused on the surgery and the anesthesia that they may not be as focused on the pharmaceutical angle. If you can have a pharmacist to follow patients throughout the process, that would be good."

Many larger hospitals have instituted what is known as an OR satellite pharmacy, according to Allen Vaida, PharmD, executive vice president of the Institute for Safe Medication Practices. If a hospital's surgical volume does not warrant a satellite pharmacy, Dr. Vaida said, it should at least seek pharmacists' input into how medications are stored, labeled and delivered to the operating room.

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No place in surgery is immune from mistakes

Medication errors occur throughout the perioperative setting, according to a newly released report that tracked voluntary incident reports from hundreds of hospitals over seven years.

Errors in clinical area Overall Harmful Deaths
Outpatient surgery 3,427 99 (2.9%) 0
Preoperative holding area 779 22 (2.8%) 0
Operating room 3,773 273 (7.2%) 2
Postanesthesia care unit 3,260 184 (5.9%) 2
Total 11,239 578 (5.1%) 4

Source: MEDMARX Data Report, "A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005," released by U.S. Pharmacopeia

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