Research Paper on Medication Errors
In the operating room, it is imperative for errors and mistakes to be limited, if not eliminated. One error that is pervasive in the surgical field is medication errors. According to the NCC MERP (National Coordinating Council for Medication Error Reporting and Prevention), a medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.” (1) This definition pertains to all facets of medicine with both prescription drugs and hospital care considered. However, the focus of this paper will be medication errors in the operating room, specifically from a perfusionist’s point of view.
Every other surgical case is reported to have a drug error or adverse drug event. (2) More so, a 2001 study found that in 121 studies where errors were reported, 48 occurred in cardiothoracic surgery, the most numerous of the study. (3) What factors specific to cardiothoracic surgery contribute to this staggering number? Could this be due to cardiac surgery being viewed as a more intensive and demanding setting? Could this perceived nature of cardiac surgery negate any safety systems that are already in place? What other aspects need to be considered that we have not already? These are all things that need to be taken into account when searching for and formulating a solution to these errors. Not just what errors are occurring, but what can we do as healthcare professionals to prevent them from reoccurring.
Many have speculated as to what the main causes of these errors could be: anaesthesiologists being the main prescribers of the operating room with no universal system for double-checking, lack of communication between the operating team, mislabeling of medications brought into the operating room, as well as lack of standardization across operating rooms.
When it comes to anesthesiologists, Wahr et al. noted specifically the “anaesthesia provider is typically the only practitioner involved in the entire process, prescribing, formulating, dispensing, and administering the medication, thus removing the protection of double-checks that exist in other hospital areas” (3). These systems of double-checking may be lost due to the aforementioned perceived nature of cardiothoracic surgery. One proposed solution is to “read and verify every vial, ampule, syringe label before administration” (2). This could help prevent medication errors as the anesthesiologist must double-check that the medication in hand is the intended medication. Additionally, the other healthcare professionals in the operating room could verify that the appropriate medication is being administered at the appropriate time.
This issue could also be due to a lack of communication between the operating team. If every medication was announced before it was administered, every individual in the operating room would be on the same page as to what stage of the procedure they are currently at. From a perfusionist’s perspective, this information is crucial. It is vital to pay attention to both the anesthesia team and the operating team, not only will their communications between each other be necessary information pertaining to your job, but the actions they are performing can give you key information as to things they are noticing, but not verbally communicating. If certain tools or medications are being used or administered, your attentiveness to these actions can help you stay prepared and on track with what is going on in the surgical field.
Unfortunately, incorrect medications are not the only form of drug administration errors. Some of the other main errors observed are incorrect dose, substitution, omission, repetition, incorrect route, and medications given to patients with known allergies. (5) Examples of each are provided by Webster et. al: incorrect doses of heparin prior to surgery, substitutions of muscle relaxants instead of muscle relaxant reversal drugs, omission in the form of propofol or continued sedation not being administered, repetition by providing unintended multiple doses of adrenaline, incorrect route in the form of medications being given via IV rather than epidurally as intended, and finally, anti-inflammatory medications given to a patient with a history of ulcers. (3) These are just a few examples to give an idea as to where these errors can occur. However, there are multitudes of other examples both reported and non-reported that need to be documented and considered.
Researchers have come up with lists of potential prevention strategies to mitigate the frequency of drug administration errors. The most common of which, that have not already been mentioned, are: formation of an incident or error reporting system, labeling every medication with name, date, and concentration, and standardizing medication layouts in trays across operating rooms. (2) Formation of an incident reporting system would be trivial if employees were not utilizing this system. Studies agree that the culture surrounding self-reporting errors is the most vital aspect to ensuring patient safety. Wahr et al. formulated a system to score the most popular and effective potential solutions by quantifying their appearance in literature. The creation of an incidence reporting system was at the top of that list consisting of the 50 most cited recommendations.
Additionally, standardized labels and layouts of medications are predicted to decrease the overall amount of medication errors. By having this system the same across operating rooms, both within hospitals and across separate centers, you would have a more streamlined arrangement that would prevent excess errors due to inattention or negligence. This could be achieved by placing medications in specific positions both on carts and in the operating rooms, as well as color coding medications based on their drug class.
Consequently, due to the lack of the aforementioned culture, one barrier to improved prevention strategies is the lack of data available. It is understandable as to why this is the case. People are afraid to self-report data that may jeopardize their employment status, and as a result, data is withheld or misreported. Operating rooms must establish a culture that allows errors and mistakes to be recorded. Once this culture is established, it would allow data to be accurately collected to ensure patient safety.
One of the required inputs would be information on errors and pre-errors. Errors would be mistakes that reach the patient, whereas pre-errors are caught and corrected before they have reached the patient. Unfortunately, as we have already mentioned, healthcare professionals are unlikely to report errors that they may have committed. This could be even more severe when it comes to pre-errors as these can be completely hidden from acknowledgement. Sadly, we just do not have a way to analyze this data without the information being reported.
When a medication error is committed the only ways to diagnose are due to patient adverse reactions or self-reporting from the administrator. Side effects can vary across the board from changes in blood pressure, changes in urine output, or even leading to the patient awakening during surgery. Nonetheless, these all require special care and treatment to mitigate any worsening conditions.
Studies vary on the overall fatality of medication errors, Webster et al. found that “no death or permanent injury to a patient was attributed to a drug error” during their study. However, Cooper et al. found that out of 67 total negative outcomes due to drug errors, 25 ultimately resulted in death. Although these numbers differ significantly, the point still remains that drug errors are an often preventable danger to patient safety.
Little can be done to treat the medication error once it has occurred. Some instances allow a reversal agent to be administered to mitigate side effects, but this is not always available. An example of a situation that would allow this would be if a patient was overly sedated after surgery and a muscle relaxant reversal agent could be administered to alleviate any unwanted paralysis. In the instances where it is not available, the patient must be closely monitored intraoperatively and postoperatively to avoid any further adverse events.
Overall, medication errors are preventable in medicine to a degree. Any efforts to increase patient safety, whether through double checks, electronic prescribing and documenting, or standardized medication labels and layouts, must be implemented when available. Ultimately, it is a group responsibility to ensure the correct medications are being administered appropriately. We all must put our pride to the side, report errors as they occur, and put patient safety at the top of importance.
