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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.

2 © 2015 Pennsylvania Patient Safety Authority

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.


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


• 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






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


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


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


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


Drug Kits • Multiple varieties and titles

• Many created spontaneously by department

• Pharmacy may not be aware

• Contain excessive types and quantities of drugs


Narcotic Exchange Kit


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Chemotherapy Surprise?


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


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


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


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



Drug Labeling

Is this the proper way?


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More Drug Labeling Issues


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


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


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
