MEDMARX® Data Report

Transcription

A Chartbook of Medication Error Findings
from the Perioperative Settings from 1998–2005
Focusing on
>> Outpatient Surgery
>> Preoperative Holding Area
>> Operating Room
>> Post Anesthesia Care Unit
U.S. PHARMACOPEIA The Standard of Quality • ISO 9001:2000 Certified
SM
Definition of Medication Error
A medication error is any preventable event that may cause or lead to inappropriate medication use or
patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice; healthcare practice; healthcare products; procedures, and systems including prescribing; order communication; product labeling, packaging, and
nomenclature; compounding; dispensing; distribution; administration; education; monitoring and use.
Definition of Harm
Impairment of the physical, emotional, or psychological function of the structure of the body
and/or pain resulting therefrom.
Source: National Coordinating Council for Medication Error Reporting and Prevention
Proper citation of this report for bibliographic purposes:
Hicks, R.W., Becker, S. C., and Cousins, D. D. (2006).
MEDMARX® Data Report: A Chartbook of Medication Error Findings from
the Perioperative Settings from 1998-2005.
Rockville, MD: USP Center for the Advancement of Patient Safety.
© 2006 The United States Pharmacopeial Convention, Inc. All rights reserved. Permission is hereby granted to reproduce this report,
in full or in part, for educational purposes provided the copyright notice is retained. Prior written permission must be obtained from
USP if the material is to be used for commercial or other purposes.
A Chartbook of Medication Error Findings
from the Perioperative Settings from 1998–2005
Dear Reader
To assist the reader in interpreting the analyses contained within this report,
the document has been organized in the following manner. First, the Executive
Summary (pages ##-#) highlights important findings and recommendations
from the perioperative setting. A brief review of the 2005 data has been included to maintain awareness that medication errors are frequent occurrences in
our nation’s healthcare system. The Background and Introduction (pages ####) leads the reader through the history of USP’s involvement in error reporting program and begins to link major public policy initiatives together. The
reader is introduced to the perioperative continuum of care, the major focus
of this report, and the populations examined. Section 1 – Medication Errors
Originating in Outpatient Surgery (pages ## - ##) provides a descriptive
summary of the findings in terms of major medication error variables and the
populations affected. The section concludes with topics that USP has identified
for further research, quality improvement efforts, or recommendations to avert
future errors. Section 2 – Medication Errors Originating in Pre Operative
Holding Area (pages ## - ##) provides a descriptive summary of the findings
in terms of major medication error variables and the populations affected. The
>> 2005 medmarx annual report
section concludes with topics that USP has identified for further research, quality improvement efforts, or recommendations to avert future errors. Section 3
– Medication Errors Originating in the Operating Room (pages ## - ##) provides a descriptive summary of the findings in terms of major medication error
variables and the populations affected. The section concludes with topics that
USP has identified for further research, quality improvement efforts, or recommendations to avert future errors. Section 4 – Medication Errors Originating
in the Post Anesthesia Care Unit (pages ## - ##) provides a descriptive summary of the findings in terms of major medication error variables and the
populations affected. The section concludes with topics that USP has identified
for further research, quality improvement efforts, or recommendations to avert
future errors. The Perioperative Technical Appendices, 1 through 9 (pages
## - ##) provides a comparative summary of the medication error variables
across the perioperative continuum. The MEDMARX Technical Appendices,
10 through 20 (pages ## - ##) provides trend information from the MEDMARX
program and includes highlights of the records received during 2005.
Table of Contents
Executive Summary______________________________________________ x
Products Implicated in Medication Errors......................................... x
Acknowledgements_ _____________________________________________ x
Error Result on Level of Patient Care................................................ x
Introduction ___________________________________________________ x
Summary of Preoperative Holding Area Medication Errors............... x
Section 1. Medication Errors Originating in Outpatient Surgery
USP Recommendations for Further Study of Medication
Errors in Outpatient Surgery___________________________________ x
Section 3. Medication Errors Originating in Operating Room
USP Recommendations to Reduce Medication Errors in the
Operating Room_ ______________________________________ x
Background........................................................................................ x
Medication Use Process in the Operating Room.............................. x
Medication Error Reporting................................................................ x
Cause of Error.................................................................................... x
Node of the Medication Use Process................................................ x
Contributing Factors.......................................................................... x
Types of Medication Errors................................................................ x
Action Taken Following an Error........................................................ x
Cross-Tabulations¬—Types of Error by Error Category Index.......... x
Products............................................................................................. x
Non-Harmful and Harmful, Pediatric Records, Outpatient Surgery..x
Level of Care Rendered Following an Error....................................... x
Causes of Medication Errors............................................................. x
Summary of Operating Room Medication Errors:............................. x
Factors Contributing to Medication Errors........................................ x
References......................................................................................... x
Actions taken following Medication Errors........................................ x
Section 4. Medication Errors Originating in Postanesthesia Care Unit
Postanesthesia Care Unit_ _______________________________ x
Products Involved in Medication Errors............................................. x
Error Result on Level of Patient Care................................................ x
Summary of Outpatient Surgery Medication Errors.......................... x
Section 2. Medication Errors Originating in Preoperative Holding Area
Preoperative Holding Area_______________________________ x
Medication Errors in Preop Holding Area.......................................... x
Medication Use Process.................................................................... x
Types of Medication Errors................................................................ x
Node of the Medication Use Process................................................ x
Products Involved in Medication Errors............................................. x
Error Result on Level of Patient Care:............................................... x
Summary of Post Anesthesia Care Unit Medication Errors............... x
References......................................................................................... x
Technical Appendices 1-9: Perioperative Comparative Findings_________ x
Technical Appendices 10-20: Historical MEDMARX Findings___________ x
Actions Taken following a Medication Error...................................... x
Glossary _______________________________________________________ x
table of contents <<
Executive Summary
N
early 200 years ago, USP was founded upon the
mission of advancing public health and this report
is but just one of the many organizational activities
undertaken to accomplish such an important mission. This year, the USP Center for the Advancement
of Patient Safety is proud to publish its seventh
report to the nation on medication errors reported to
MEDMARX. USP is a standards-setting organization
that connects to practitioners through the bylaws and
operations of the USP Convention.
This report is a reflection of how USP works with practitioners, educators,
and other professional organizations in a matrix format to satisfy the core
mission of advancing public health. The theme of this report, an analysis of
seven years of medication errors in the perioperative continuum – outpatient
surgery, pre-operative holding area, operating room, and the post anesthesia
care unit – came from such a working relationship and represents the largest
known analysis of perioperative medication error records. The genesis of this
report began when the Uniformed Services University of the Health Sciences
adopted a class project on medication safety and partnered with USP. As the
project grew over time and in scope, USP turned to other expert perioperative
clinicians and professional organizations in order to share the information and
further disseminate through the production of this report.
USP began publishing the Data Report in chart book style two years ago in
order to provide the health services research community with detailed medication error information. This Report remains in the same style and adds a new
dimension of patient population. Therefore, the resulting matrix examines each
clinical location by all records, pediatric records, adult records, and geriatric
2 >> 2005 medmarx annual report
records. As a result of these additional analyses, the reader gleans a clearer picture of the risks by population associated with safe medication use in the perioperative setting. Consistent with the previous two reports, aggregated general
MEDMARX information is contained in the technical appendices, spanning
2001 through 2005.
Highlights of this year’s MEDMARX Data Report include:
Medication Errors in the Outpatient Surgery Department (Section 1)
4 T
he number of reported errors was 2,437 with 3.3% of the errors resulting
in harm. Harm was present in each of the populations: pediatrics (3.6%),
adults (5.1%), and geriatrics (5.1%). Three events required life sustaining
interventions to preclude death.
4 T
he three most common types of errors were: Prescribing errors, Omission
errors, and Improper dose/quantity (wrong dose) errors. Together, these
errors represented two-thirds of the errors. Pediatric patients were disproportionately affected by Improper dose/quantity errors while Omissions
errors were present in over one-third of the adult and geriatric records.
4 T
he three leading causes of errors were consistent across the sample and
included Performance deficit, Procedure/protocol not followed, and
Communication.
4 P
roducts most commonly involved in errors included antimicrobial (i.e.,
antibiotics) agents and central nervous system agents. When examining
errors associated with harm, central nervous system agents were most
common.
riority areas that USP has identified for further investigation in the
P
Outpatient Surgery Department includes:
4 A
ddressing the influence of Contributing Factors (e.g., Distractions) that
may play a role in the medication error;
4 D
evising strategies around medications (such as midazolam or other controlled substances) that have a high risk for harm by understanding the
causes of these errors;
4 E
xpanding the pharmacy department’s role in perioperative care by having dedicated staff that participate in the medication use process, including
medication reconciliation and standardizing (or limiting) the products routinely available,
4 Adopting a culture of safety and error reporting;
4 Exploring the use of electronic health records to avoid loss of information;
4 Expanding the use of bar-code medication administration systems;
4 E
mpowering patients to participate in pre-procedure safety activities, such
as preregistration, marking the surgical site, , providing history and physical
information, including current medications, allergies and participating in
medication reconciliation;
4 E
nsuring that patients and their corresponding chart forms are properly
identified;
4 R
eviewing all institutionally developed labels for adequate font size and
permanency of ink (to avoid smears).
Medication Errors in the Preoperative Holding Area (Section 2)
4 T
he number of reported errors was 779 with 2.8% of the errors resulting in
harm. Harm was present in each of the populations: pediatric (4.2%), adult
(7.1%), and geriatric (2.6%). One adult case required intervention to sustain
life.
4 D
eveloping check lists that are accurately completed prior to patients leaving the area to minimize the loss of information through hand-offs;
4 T
he two most common types of errors were: Wrong time and Omission
errors, a pattern seen in the pediatric and adult records. Geriatric records
also implicated Unauthorized/wrong drug as a leading type of error.
4 D
eveloping strategies to ensure that medications are administered at the
correct time, especially antimicrobial agents;
4 H
and-offs and the loss of information through incomplete or adequate
documentation contributed to many of the errors.
4 Implementing strategies that adequately identify and communicate allergy
information and other clinical information to all members of the perioperative team;
his Report identifies recurring problems originating in the preoperaT
tive holding area and USP suggests the following:
4 Resolving duplicate or conflicting medication orders;
4 E
xpanding the use of weight conversion charts and redesigning chart forms
to express patient’s weight in kilograms, such that the healthcare providers
can rapidly identify the correct the patient’s weight for use in clinical care;
4 E
nsuring that calculations are accurate throughout the medication use process, and by using an independent or technological double-check system
especially in the pediatric population;
4 R
eviewing preprinted orders to ensure appropriate clinical alternatives (e.g.,
in the case of allergies), and the appropriate use of abbreviations;
4 Reducing the reliance on verbal orders;
4 C
onfirming the processes for correct patient identification and correct surgical site, especially if patient has been premedicated before coming to the
preoperative holding area;
4 E
liminating the potential for accidental administration of neuromuscular
blocking agents in the Preop holding area;
4 D
eveloping or utilizing sufficient documentation that tracks patients
through the continuum of care, and addresses the issues of “hand-offs” and
lost information;
4 E
nsuring that sufficient staff members are available to administer pre-procedural/preoperative antimicrobial agents in a timely and thorough fashion,
including the validation that the “piggy-back” was properly activated;
EXEcutive summary << 3
4 E
xpanding the opportunities for surgical team communication and
collaboration to address issues of patient readiness as they relate to scheduling;
4 E
stablishing documentation standards to ensure that preoperative drugs
have been given, IV sites are patent and the correct IV infusion is present, allergies are noted, and the patient’s condition is documented prior to
releasing the patient to the surgical suite;
4 E
xpanding the use of satellite pharmacy support such that medications are
readily available and prepared within the area where the medications are
being administered;
4 R
esearch or other investigations are needed to determine why policies
and procedures are not being followed (given the high number of errors
associated with this cause). Such activity should determine if the policies
are incomplete, inaccurate, or missing as well as determining that staff are
aware of the policies and able to appropriately comply;
4 H
ealthcare should further investigate and implement concepts of teamwork
and train staff to accommodate workload demands through cooperation
and adequate planning.
Medication Errors in the Operating Room (Section 3)
4 T
in harm. Harm was present in each of the populations: pediatric (16.7%),
adult (11.3%), and geriatric (10%). Nine events required intervention to
sustain life and two medication errors contributed to patient deaths.
hospitals should obtain as many products in sterile ready-to-use packaging
as possible;
4 A
multidisciplinary team should periodically examine preference cards
(physician requirements for a particular procedure) to ensure appropriate
use of abbreviations or acronyms, ensure clarity of medications intended
for the procedure, affirm instruments and equipment needed for the case.
There should also be evidence to the last date the card was reviewed. To the
extent possible, facilities should adopt technology consistent with the benefits of CPOE.
4 T
o the extent possible, institutions should have dedicated satellite pharmacies and a sufficient number of appropriately stocked automated dispensing
devices to provide medications used in connection with the procedure.
4 P
ractitioners should have access to accurate patient information, standardized dose charts, and/or assistive technologies with proper medication
calculations and formulations so no patient will be at risk of receiving the
wrong dose of drug.
4 H
ealth care practitioners should strive for the establishment and maintenance of a culture of safety and open communication, which includes
appropriate “briefing and debriefing”. Event reporting and documentation
of system’s level actions must be included in the culture of safety.
4 T
he “Time-Out” standard should be expanded to allow sufficient review of
the preference card, confirmation of the medication directions, confirmation
of patient allergies, and confirmation of pre-procedural antibiotics.
4 T
he three most commonly reported types of errors overall included
Omission error (21.4%), Unauthorized/wrong drug (20.6%), and Prescribing
error (17%). In the pediatric population, errors involving an improper dose/
quantity (32.4%) was the most common type of error, whereas, the adult
and geriatric population were similar to errors overall.
4 P
ractitioners should adhere to the practice of ‘repeat and verification’ during hand off between scrub personnel and surgeons.
4 Misusage of high alert medications often resulted in harmful outcomes.
4 V
erbal communication between circulating nurse and scrub personnel must
be clear and both must confirm the drugs on the sterile field as well as the
labelling of the drugs on the field.
Priority areas that USP has identified for further improvement are:
4 Institutions and professional associations should call upon manufacturers
to produce drug products in ready-to-use packaging with sterile, duplicate
labels to avoid errors with labelling. As soon as commercially available,
4 P
ractitioners must examine policies and procedures for accuracy and clarity. Institutions must examine why policies are not being followed, which
may include an assessment of the practitioner’s awareness of the policies.
4 L
abelling of all medications should be done to accommodate the needs of
the anesthesia provider as well as the sterile field. Labelling should be done
in accordance with generally accepted safety standards (product name,
strength, staff preparing, etc).
4 E
nsuring that calculations are accurate throughout the medication use process by providing weight conversion charts and maximum dosing charts,
4 O
riginal research is needed to investigate how electronic or computer entry
integrates with the electronic health record in this unique environment.
4 A
dhering to appropriate staffing guidelines as directed by the patient population served,
4 L
eadership should have better understanding of the actions taken in
response to an error in order to determine which interventions are most
likely to result in sustained changes and reduce the burden of medication
errors.
4 R
educing the potential for dose-versus-volume errors (i.e., 0.6 mg versus
0.6 mL) through obtaining products in the final ready-to-use dose.
4 C
onfirming the processes for correct patient identification and correct surgical site, especially if patient has been medicated. A parent and/or family
member should be present and serve as the proxy for verifying pediatric
patient identification and surgical procedure.
Medication Errors in the Post Anesthesia Care Unit (Section 4)
4 T
in harm. Harm was present in each of the populations: pediatric (20.3%),
adult (8.7%), and geriatric (8.8%).
4 T
he leading types of errors were Prescribing errors (24%) and Improper
dose/quantity (21.2%). Pediatric patients had a greater percentage of
Improper dose/quantity (38.7%) errors than any other group.
4 P
atient controlled analgesia machines were often implicated in the most
harmful errors.
4 Many harmful errors were the result of tubing misconnections
4 T
he absence of clearly identifiable and easily obtainable allergy information
predisposed many patients to risk.
riority areas USP recommends for further multi-disciplinary investiP
gation include:
4 U
sing the FMEA approach, develop explicit heuristic educational and training strategies that ensure the safe use of intravenous and epidural patient
controlled analgesia pumps,
4 R
equiring forcing functions be developed by vendors and adopted by
healthcare systems that prevent tubing misconnections
4 T
ranslating the principles of ASPAN’s position statement on Safe
Medication Administration into practice,
4 D
edicating pharmacy personnel to support PACU that review all medication orders, evaluate medications routinely stocked in the area, assist with
the medication reconciliation process, and assist with obtaining standardized dosing to the extent possible.
4 E
nsuring the elimination of abbreviations for compliance with National
Patient Safety Goals.
4 E
ncouraging reporting of medication errors and other adverse events in
order to learn from the errors.
While this report strictly focuses on perioperative medication errors, during
2005 MEDMARX collected 221,000 medication errors, with 1.33% resulting
in harm – continuing a downward trend in the percentage of records associated with harm (Technical Appendix 10). The percentage of dispensing errors
rose again for the second year in a row (Technical Appendix 11). Again,
errors often involved the wrong amount (Technical Appendix 12). The four
leading causes of errors were essentially unchanged (Technical Appendix 14).
Distractions were the leading contributing factors (Technical Appendix 15).
The five leading products (insulin, morphine, potassium chloride, albuterol and
heparin) involved in errors were unchanged from our 2003 report (Technical
Appendix 18). Insulin, morphine, and heparin remained the leading products
associated with harm (Technical Appendix 19). The 2005 records came from
590 facilities and included 17 deaths. The details of these error events can
be found in Technical Appendix 20. The products implicated in these deaths
include enoxaparin, flecainide, gentamicin, hydromorphone, morphine, potassium chloride, potassium phosphates, sodium bicarbonate, spironolactone, total
parental nutrition, and venlafaxine.
EXEcutive summary << 5
Acknowledgements
Uniformed Services University of the Health Sciences (USUHS)
Bethesda, Maryland
T
his Report is the keystone of a 3-year research partnership between USP
and the Uniformed Services University for the Health Sciences (USUHS)
Graduate School of Nursing (GSN). What began as a single project on medication safety has turned into a program of study for the students. The USUHS
GSN houses the nation’s only dedicated perioperative clinical nurse specialist
program. The faculty and active duty military officers associated with the perioperative program have participated with USP in the analysis and evaluation
of this data as they learn to care for those in harms way. The GSN Class of
2005 began with a project that examined all reported perioperative medication
errors. The GSN Class of 2006 focused on pediatric medication errors across
the perioperative continuum and the 2007 class analyzed medication errors
involving geriatric patients. As experts in perioperative care, these dedicated
individuals made invaluable contributions to the analysis and interpretation of
the findings contained within this report. USP would like to thank the following individuals for their substantial effort in contributing to this report:
Perioperative Clinical Nurse
Specialist Faculty
Joanna M. Bourne, M.S.N., R.N., CNOR
Major, U.S. Air Force Nurse Corps
Perioperative Clinical Nurse Specialist
Class of 2006
Linda J. Wanzer, M.S.N., R.N., CNOR
Colonel, U.S. Army Nurse Corps
Consultant, U.S. Army Surgeon General
Uniformed Services University of the Health
Sciences
Bethesda, Maryland
Janet M. Bradley, M.S.N., R.N., CNOR
Commander, U.S. Navy Nurse Corps
Lisa M. Cole, M.S.N., R.N., CNOR
Tara N. Constantine, M.S.N., R.N., CNOR
Captain, U.S. Air Force Nurse Corps
Vivian M. Devine, M.S.N., M.B.A., R.N., CNOR
Commander, U.S. Navy Nurse Corps
Michael A. Gladu, M.S.N., R.N., CNOR
Major, U.S. Army Nurse Corps
Dennis E. Glover, M.S.N., M.B.A., R.N., CNOR
Lieutenant Commander, U.S. Navy Nurse Corps
BradLee E. Goeckner, M.S.N., R.N., CNOR
Lieutenant, U.S. Navy Nurse Corps
Kelly C. Nader, M.S.N., R.N., CNOR
Jason A. Nelson, M.S.N., R.N., CNOR
Laura E. Newkirk, M.S.N., R.N., CNOR
Christopher H. Payne, M.S.N., M.P.A., R.N.,
CNOR
Cheryl Reilly, M.S.N., R.N., CNOR
Lieutenant Colonel, U. S. Air Force Nurse Corps
Mike O’Callaghan Federal Hospital
Nellis Air Force Base, Nevada
Class of 2005
Ava M. Bivens, M.S.N., R.N., CNOR
Antoinette M. Shinn, M.S.N., R.N., CNOR
Thomas O. Rawlings, M.S.N., R.N., CNOR
Captain, U.S. Army Nurse Corps
Christopher R. Smith, M.S.N., M.A., R.N., CNOR
Lieutenant Commander, U.S. Navy Nurse Corps
Theodore J. Walker, M.S.N., R.N., CNOR
Class of 2007
Monique R. Courts-Carter, B.S.N., RN
Stacey S. Freeman, B.S.N., R.N., CNOR
Mary J. Harvey, M.A., B.S.N., R.N., CNOR
Gregory L. Lara, B.A., B.S.N., R.N., CNOR.
Robert D. Smith, B.S.N., R.N., CNOR
Theresa A. Vernoski, B.S.N., R.N., CNOR
The information contained in this report
may not represent the official views of the
Department of Defense, the Uniformed
Services University of the Health Sciences,
or the United States Government.
USP would like to thank the following individuals
for the substantive review of this report:
USP Safe Medication Use Expert
Committee 2005-2010
Suzanne C. Beyea, Ph.D., R.N., F.A.A.N.
Director of Nursing Research
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
Maureen Cahill, M.S.N., R.N.
Senior Clinical Manager
Banner Children’s Hospital
Mesa, Arizona
Elizabeth A. Flynn, Ph.D., R. Ph.
Associate Research Professor
Auburn University
Artesia, New Mexico
Howard Greenberg, M.D., M.S., M.B.A.
Medical Director, Clinical Pharmacology
Bristol-Myers Squibb Co.
Hamilton, New Jersey
Matthew C. Grissinger, R. Ph., F.A.S.C.P.
Medical Safety Analyst
Institute for Safe Medication Practices
Huntingdon Valley, Pennsylvania
Mark L. Horn, M.D.
Medical Director/Government Relations
Pfizer, Inc.
New York, New York
William N. Kelly, Pharm. D.
President
William N. Kelly Consulting, Inc.
Clearwater, Florida
Gerald K. McEvoy, Pharm. D.
Assistant Vice President, Drug Information
American Society of Health-System Pharmacists
Bethesda, Maryland
Michael D. Murray, Pharm. D. (Chair)
Mescal S. Ferguson Distinguished Professor
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Ron Nosek, M.S., R. Ph., F.A.S.H.P.
Commander, Medical Service Corps
United States Navy
National Naval Medical Center
Bethesda, Maryland
Marjorie A. Phillips, M.S., R. Ph., F.A.S.H.P.
(Vice Chair)
Medication Safety Coordinator & Clinical
Research Pharmacist
Medical College of Georgia Health System
Augusta, Georgia
Deborah Simmons, M.S.N., R.N., CCRN, CCNS
Senior Clinical Quality Analyst
MD Anderson Cancer Center
Houston, Texas
John Straumanis, M.D.
Associate Professor of Pediatrics
University of Maryland, School of Medicine
Baltimore, Maryland
Mark Sullivan, Pharm. D., M.B.A., BCPS
Assistant Director, Decentralized Services
Pharmacy
Vanderbilt University Medical Center
Nashville, Tennessee
Kathleen Uhl, M.D.
Assistant Commissioner for Women’s Health
Director of FDA’s Office of Woman’s Health
Rockville, Maryland
Acknowledgements << 7
American Society of PeriAnesthesia Nurses
(ASPAN)
Cherry Hill, New Jersey
Nancy Burden, M.S., R.N., CPAN
Mortan Plant Mease Health Care
Clearwater, Florida
Ellen E. Sullivan, B.S.N., R.N.. CPAN
American Society of PeriAnesthesia Nurse
Cherry Hill, New Jersey
Dina Krenzischek, M.A.S., R.N., CPAN
Johns Hopkins Hospital
Baltimore, Maryland
Linda Wilson, Ph.D., R.N., CPAN, CAPA, BC
Drexel University
Philadelphia, Pennsylvania
AORN - Association of periOperative
Registered Nurses
Denver, Colorado
Christine R. Bloomfield, M.S.N., R.N., CNOR
Glenbrook Hospital
Glenview, Illinois
Joan Blanchard, M.S.S., R.N., CNOR, CIC
AORN
Denver, Colorado
Ramona Conner, M.S.N., R.N., CNOR
AORN
Denver, Colorado
Bonnie Denholm, M.S., R.N., CNOR
AORN
Denver, Colorado
Linda K. Groah, M.S.N., R.N., CNOR, CNAA,
F.A.A.N.
Kaiser Foundation Health
San Francisco, California
Charlotte Gugliemi, B.S.N., R.N., CNOR
Beth Israel Deaconess Medication Center
Boston, Massachusetts
Sharon McNamara, M.S., R.N., CNOR
WakeMed Health and Hospitals
Raleigh, North Carolina
* USP has a research and publication agreement
with Johns Hopkins University
Carol Petersen, M.A.O.M., R.N. CNOR
AORN
Denver, Colorado
Independent Expert
Sharon Giarrizzo-Wilson, B.S.N./M.S., R.N.,
CNOR
AORN
Denver, Colorado
Linda J. Wanzer, M.S.N., R.N., CNOR
Colonel, U.S. Army Nurse Corps
Consultant, U.S. Army Surgeon General
Uniformed Services University of the Health
Sciences
Bethesda, Maryland
Donna Watson, M.S.N., R.N., A.R.N.P., CNOR
Cascade Vascular.
Takoma, Washington
The Johns Hopkins University School of
Medicine* and the Johns Hopkins University
Bloomberg School of Public Health*
Eugenie Heitmiller, M.D., FAAP
Associate Professor of Anesthesiology and
Pediatrics
Peter Pronovost, M.D., Ph.D.
Professor, Departments of Anesthesiology and
Critical Care, Surgery,
And Health Policy and Management
Director, Johns Hopkins Quality and Safety
Research Group
Medical Director, Center for Innovations in
Quality Patient Care
Jerry Stonemetz, M.D.,
Clinical Associate
Julie Golembiewski, Pharm. D.
Clinical Associate Professor
University of Illinois at Chicago
USP Center for the Advancement of Patient
Safety Staff
Marsha M. Protzel, B.S., R.N.
QA/QC analyst
Marilyn Storch, B.S.
Coordinator, Patient Safety Projects
University of North Carolina
Center for Education and
Research on Therapeutics
The pediatric component of
this study was partially funded by the Agency
for Healthcare Research and Quality as part
of the University of North Carolina Center for
Education and Research on Therapeutics (UNC
CERTs) (Harry Guess, CERTs PI; award number
U18 HS 010397).
Since 1999, the dual mission of the UNC CERTs,
as the only CERTs devoted to improving therapeutic use in the pediatric population, has been
to conduct and then disseminate vital therapeutics research for the benefit of the pediatric
population. From its administrative home in the
University of North Carolina’s Internationally
ranked Department of Epidemiology and the
UNC Program on Health Outcomes, the UNC
CERTs provides broad attention to practical
improvements with a targeted emphasis on mainstream problems in therapeutics and then concentrates these focal points on improving outcomes
Introduction
ince, the 1999 IOM report on health care quality, interest in successful
reporting programs is high. There is a need for healthcare leaders to fully
understand the components of an error reporting program and the scope of
reporting activities. This implies that an interdisciplinary team that represents
content domain, legal experts, and analysts, must be in place to move beyond
simple collection to a level of in-depth analysis and impact. Event reporting
must also move beyond a practitioner-based function to one driven reciprocally
by and for practitioners and administrators. When this occurs, the event report
process will help organizations learn from mistakes and lead to better decision
making in designing a safer health care system and maintain compliance with
regulatory and accreditation standards.
In 1999, the IOM called upon the healthcare system to voluntarily participate in
medical error reporting programs to reduce the occurrence of harmful events.
Voluntary, confidential1 error reporting programs that collect data from multiple organizations allow identification of errors due to system failures that may
be rare events for individual organizations. Such reporting systems provide rich
information for organizations to support quality improvement activities and
are useful in the prevention of future errors. Analyzing medication errors is
more than just counting and reporting events. Sponsors of reporting programs
bear the responsibility of sharing findings from aggregate analyses that promote
systems-oriented changes, learning, and safety in a timely fashion.1 Currently,
there is a variety of voluntary and mandatory reporting systems in operation.
Voluntary program can operate at the institutional level, the state level, or the
national level.2 In voluntary programs, the focus is on learning from “near1 Confidential includes de-identified reporter information, de-identified patient information,
and de-identified facility information.
miss”, actual, or severe events that often result from the wide spread system
vulnerabilities. Voluntary programs have been successful in increasing staff
awareness of medication safety issues.1, 3 Mandatory state reporting programs
are present in about half of the states4 and have the focus on accountability.
Mandatory systems often collect data about the most severe events. Because
these programs are sponsored by state agencies, there remains the possibility
that disciplinary actions may result. Both types of reporting programs possess
the potential to improve medication safety through dissemination of the analysis of events reported, thus leading to evidence to support “best practices”.2
For the past 15 years, The United States Pharmacopeia has been engaged in
voluntary medication error reporting programs: the USP Medication Errors
Reporting (MER) Program, which is presented in cooperation with the Institute
for Safe Medication Practices (ISMP), and MEDMARX – a subscription-based,
medication error reporting program. Both programs offer proof-of-concept
that practitioners are willing to report medication error experiences that lead to
safer patient care.
In 2000, medication safety researchers from The United States Pharmacopeia
(USP) created the USP Medication Safety Program Model for Hospitals &
Health Care Systems. The model (Figure 1) has two main drivers (the health
care facility and error identification) that lead to three core domains (collection,
analysis, and impact).
In 2004, European anaesthesia providers described the framework of a reporting system (see Figure 2) for purposes of creating a dynamic process to improve
patient safety.5 Event reporting systems can be powerful tools when the findings are used to improve systems and educate providers.6 The intent behind
introduction << 9
introduction
S
Figure 1. USP Medication Safety Model
USP Medication Safety Program Model
For Hospitals & Healthcare Systems
Assess Effectiveness
introduction
(Information, Dissemination Strategies, and Intervention)
HEALTHCARE
FACILITIES &
PROVIDERS
Leadership
commitment
n Safety
Culture
n
Mechanisms of
Error Identification
• Sopontaneous
reporting
• Direct observation
• Retrospective
chart review
• Triggers
COLLECTION
Who report
How to report
n Types of
n
n
events and
data elements
n Potential
reporting
incentives/
deterrents
= Detection
Sensitivity
Level (DSL)
Data
Elements
analysis
Types of Analysee
n Coding
> Standardized
harmony
n Coutning
n Sorting
n Trending
n Signals
n Data-mining
n Process
mapping
n Root cause analysis
n Failure mode
effects and
criticality
analysis
such a system is to collate and analyze the risks associated with medication
activities in order to propose remedial and preventive actions1 A reporting
system is inclusive of multiple components: empirical and theoretical models, a
variety of tools built from domain content, and analysis by domain experts.4, 5
Strategies are derived from the analysis and implemented, followed by on-going
monitoring, evaluating, and adjusting as necessary.7 This systems approach
recognizes that errors are symptoms of a deficient system, not deficiencies in
people 8
Leape (2002) identified seven characteristics of successful reporting systems
based on published expert opinions. The characteristics are non-punitive (free
Communication
• Informaiton
formats
• Recipients of
information
• Targeted
messsages
and alerts
impact
LEVEL 1
n Volume of reporter
n Types of reports
(severity)
n Costs of
medication errors
from fear of retaliation), confidential (de-identified patient,
reporter and institutional information), independent (analysis
done by organization without
power to punish), expert analysis (content experts), timely
(prompt), responsive (dissemination of results), and systemsoriented (focus on changes in
systems and processes rather
than individual performances).
MEDMARX epitomizes a
national example of a successful
reporting system.
USP considers each medication error report submitted to
MEDMARX as a record which
reflects either an actual or potential medication error event.
LEVEL 3
Each record contains a number
n Safety
of fields as depicted in Figure
improvements
n Redcued injuries
3. Some of the fields (e.g.,
n Financial impact
Node) are single-select indicating that each unique record
contains only one selection (e.g.,
Prescribing). Some of the fields are multi-select (e.g., Type of Error), indicating
that a unique record may contain more than one selection (e.g., Wrong patient
and Improper/dose quantity). Therefore, the number of records may differ
from the number of selections reported when the findings relate to a multiselect field. Where appropriate, the number of records has been identified as
well as the total number of selections associated with those records.
LEVEL 2
n Action taken
> Staff
> Systems
> Costs of
interventions
Participating facilities (hospitals and their related healthcare systems) submit medication error records to MEDMARX as part of their ongoing quality
improvement activities surrounding the medication use process. The charac-
Figure 2:Conceptual Model of Error Reporting
(Source: Nyssen et al., 2004)
Major medication error fields include
4 Node – This single-select field identifies where the initial medication error
occurred in the medication use process (i.e., Procurement, Prescribing,
Transcribing/Documenting, Dispensing, Administering, or Monitoring).
Node is applicable to Categories B through I.
4 Types of Error – The field denotes the kind of error that occurred. There
are 14 medication error types included in the multi-select pick list (e.g.,
Wrong patient, Wrong time, Omission error).
4 Causes of Error – This multi-select pick list denotes the 62 causes associated with a medication error (e.g., Brand names look alike, Abbreviations,
Handwriting illegible/unclear).
4 Contributing Factors – This multi-select field comprises a 20-item pick list
that provides information about factors that influence a medication error
(e.g., Poor lighting, Workload increase, or Emergency situation).
teristics of facilities that contributed to the perioperative portion of this report
are summarized in Perioperative Technical Appendix Number 1.
MEDMARX collects medication error event data in a standardized format
through a series of required and optional fields. Most fields contain a list of possible selections (i.e., a pick list) that guides the reporter to document specific
information. A glossary of terms is provided at the end of this section.
4L
evel of Care Rendered as a Result of the Error – This multi-select field
describes up to eight clinical aspects of care that might be rendered after a
medication error occurs (e.g., Observation increased, Oxygen administered,
Hospitalization prolonged). The data serve as surrogate markers for resources expended in response to an error event.
4 Actions taken – This multi-select field contains 13 items that document the
organization’s response to a medication error (e.g., Informed staff that made
the initial error, Policy/procedure changed, Environment modified).
introduction << 11
introduction
4 Error Category Index – This single-select field captures whether or not
a medication error occurred, and if it occurred, its effect on the patient.
Using the National Coordinating Council for Medication Error Reporting
and Prevention (NCC MERP) Index for Categorizing Medication Errors,
Category A represents circumstances or events that have the capacity to
cause error. Category B indicates that a medication error has occurred but
it did not reach the patient (i.e., intercepted). Categories C and D designate
medication errors that have occurred but did not result in patient harm.
The varying levels of patient harm are reflected in Categories E, F, G, and H.
A medication error that resulted in, or may have contributed to, a patient’s
death is classified as Category I.
Figure 3. MEDMARX Fields and Information Collected
Categories C - I Records
Required (13) 
introduction
Category B Records
 
Required (10) 
Category A Records
 
Required (7) 
> Error category
> Source of record
> Date potential error
was discovered
> Description of potential
error
> Types of potential error
> Causes of potential error
> Location of potential error
Optional (23) 
> Product by generic name
> Brand name
> Manufacturer
> Therapeutic class
> Dosage form
> Intended route of
administration
> Labeler
> Compounded ingredients
> Investigational drug name
 > Strength/concentration
 > Type of container
> Size of container
> Number of occurrences
> Time of error
> Source of error
> Location of detail
> Level of staff that
discovered the
potential error
> Action taken to avoid
similar error
> Action taken and
recommendations to
avoid future similar error
> Internal control
> Device involved
> Miscellaneous 1
> Miscellaneous 2
> Error category
> Source of record
> Date of error
> Description
> Types of error
> Causes of error
> Contributing factors
> Node
> Location of initial error
> Level of staff that made
initial error
administration
> Labeler
 
> Strength/concentration
 > Type of container
 > Size of container
 > Number of occurrences
> Time of error
> Source of error
> Location detail
> Root cause analysis
summary
perpetuated the error
discovered the error
similar error
> Action taken and
recommendations to
> Internal control
> Device involved
> Miscellaneous 1
> Miscellaneous 2
> Contributing factors
> Level of staff that made
initial error
patient care
Optional (29) 
> Brand name
> Manufacturer
> Therapeutic classification
> Dosage form
> Intended route of
Optional (25) 
> Brand name
> Manufacturer
> Therapeutic classification
> Dosage form
> Intended route of
> Error category
> Source of record
> Date of error
> Error description
 > Node
 > Types of error
 > Causes of error
> Location of initial error
> Patient age
> Error result on level of
administration
> Labeler
> Strength/concentration
> Type of container
 > Size of container
 > Number of occurrences
 > Source of order
> Location detail
 
> Root cause analysis
  summary
 > Time of error
perpetuated the error
discovered the error
similar error
> Action taken and
recommendations to
> Internal control
> Gender
> Details of error result on
level of care
> Tests/labaratory data,
with dates, if relevant
to the error
> Other patient history,
including pre-existing
medical conditions, if
relevant to the error
> Concomitant drug therapy,
with dates, if relevant to
the error
> Device involved
> Miscellaneous 1
> Miscellaneous 2
 
4 Products – This field provides the generic (nonproprietary) and/or brand
(proprietary) name, manufacvturer, and therapeutic classification of the
product(s) involved in the medication error. Products associated with
records are entered by the users from the MEDMARX product table and
may reflect the product intended for use, the product not intended for use,
or both. When applicable, products with the same generic name have been
combined regardless of dosage form or product formulation (e.g., all oral
and parenteral forms of morphine sulfate).
Introduction to Perioperative Environments
World-wide, surgery has occupied a central role in health and healing throughout the ages9 and is thought to have its origin in the management of wounds.10
The earliest writings about infection were authored by Hippocrates around the
fifth century B.C., but it was another millennium before Gerolamo Fracastoro
wrote his treatise De Contagione in which he stated what was, in effect, the
modern theory of infection by microorganisms.10 As recently as the turn of the
19th century, surgical practice was chaotic and outcomes varied widely.11 In
the mid 1800’s, Florence Nightingale sought to improve sanitary conditions in
medical facilities by proving the effectiveness of proper hygiene for the recovery
of wounds and disease, which led to the reformation of the entire English military hospital system.12 Nightingale proved her case through statistical analysis, using what she called “coxcombs”, now known as, “polar-area diagrams.”
Antiseptic treatment became recognized around 1870, following the epochmaking research by Joseph Lister.10 A decade later, fractional sterilization,
which became the basis for aseptic technique was introduced. Sterile gowns
and caps soon followed but it was another two decades before surgeon’s gloves
were widely used.10 Like surgery, advances in anesthesia has a long history that
includes the administration of nitrous oxide, morphine, ether, chloroform and
other agents (i.e., muscle relaxants) as adjuncts to surgery.10 Surgeries that were
As early as 1908, the surgical community became actively engaged in identifying and reducing risk associated with surgery and defined quality as a goal in
treating patients.16 These desirable attributes have been part of the transformation of health care over the past several decades. While the U.S. has the
capacity to produce the finest health care services in the world, failures in the
delivery system have been widely reported; and the failures occur with some
regularity.17 Medical errors, including medication errors, represent one such
failure that injures patients, erodes public confidence, and increases healthcare costs.18 The healthcare professional’s knowledge of medication errors
has increased substantially, in part due to widely publicized national reports,
activities of leading healthcare organizations, and the published findings from
national medication error reporting programs. The Institute of Medicine’s
(IOM’s) series on the quality of the U.S. healthcare system suggest that additional transformations are needed to deliver effective, efficient, and equitable
patient care. The IOM series explicitly states that patient safety is the expected
standard of care in healthcare.
This Report examines 11,239 perioperative medication errors reported to
MEDMARX between September 1, 1998, and August 31, 2005, and offers a
descriptive and comparative view of experiences in the perioperative continuum, which encompasses four distinct clinical areas:
introduction << 13
introduction
4 Patient age – This variable identifies the age of the patient involved in the
error. Pediatric patients are defined as individuals less than 17 years of age.
Adults are represented by ages 17 through 64 and geriatric patients are those
individuals 65 years of age and over. The variable is only available for errors
that reach the patient (Categories C through I).
once considered fatal or impossible were performed with increasing regularity, skill, and success.13 Parallel to these advances came the development of
more refined equipment, surgical instruments, dressings,13 and pharmaceutical
products. By the late 1800’s, specially constructed rooms for surgery were provided and furnished with modern equipment of the era.13 The United States
now has the world’s most advanced surgical system and it includes the use of
highly skilled health professionals, a broad array of pharmacological agents, and
state-of-the-art medical and surgical technologies.14 As with any location that
involves healthcare providers, pharmacological agents, and patients, the opportunities for medication errors abound. The National Center for Health Statistics
reported that in 1996 there were nearly 72 million surgical and nonsurgical
procedures performed on 39.9 million ambulatory and inpatient discharges
combined.15 Each healthcare encounter can present multiple opportunities for
error. The National Center for Health Statistics is currently gathering information the number of surgeries performed annually and expects to release an
updated report in 2007.
Table 1. Overview of Perioperative Medication Errors, by Location and by Population
All Records
Clinical area
Adult
Geriatric
Age not Provided
n
%
n
%
n
%
n
%
n
%
3,427
30.5
84
29.6
1,081
28.9
606
29.4
1,656
32.1
779
6.9
15
5.3
239
6.4
151
7.3
374
7.3
Operating Room
3,773
33.6
126
44.4
1,272
34
689
33.5
1,686
32.7
Post Anesthesia Care Unit
3,260
29
59
20.8
1,153
30.8
613
29.8
1,435
27.9
Outpatient Surgery
Preoperative Holding Area
introduction
Pediatric
Total
11,239
284
4 Outpatient Surgery (OPS) – Section 1 (Pages ## - ##)
4 Preoperative (Preop) - Section 2 (Pages ## - ##)
4 Holding Area, the Operating Room (OR), - Section 3 (Pages ## - ##)
4 Post Anesthesia Care Unit (PACU) – Section 4 (Pages ## - ##)
4 Comparative findings across the continuum are contained in Technical
Appendices 1-9 (Page ## - ##)
In addition to the clinical locations, this report further examines the errors in
two ways. First, All Records, which reflects the summary of any record meeting the criteria for the variable and, as such, represents the study population.
Second, from the population, this report provides detailed descriptive information on three specific samples, Pediatric (less than 17 years of age), Adult
(between 17 years and 64 years of age), and Geriatric (greater than or equal to
65 years of age), and one general sample, Age not Provided (meaning no age
was required or specified). The high numbers of voluntarily reported errors in
each location provide important information about the vulnerabilities and risk
points affecting the patients in the healthcare system (Table 1).
In order to preserve the representativeness of the findings for each specialty
area, each section of this Report is intentionally designed to be self-contained
3,745
2,059
5,151
with background, implications, and findings. Each section concludes with a
summary and priorities for patient safety pertinent to the specific area of practice. Many of the solutions proposed will affect workload and institutions, and
in some, the manufacturers, are called up to provide the necessary additional
resources to meet these needs. As a result of this design, some implications may
seem repetitive.
Case vignettes of actual errors reinforce the patterns noted within this Report.2
The cases reviewed in this Report represent the some of the challenging practices issues that threaten patient safety. Other cases identify clinical practice
issues (such as the use of meperidine in elderly patients, metoclopramide for
post operative nausea, or what may seem as too easy access to intravenous
digoxin). While the issues are important, it is not the intent of this report to
judge a practitioner’s decision making, but rather, demonstrate the additional
value of participating in a voluntary reporting program such that further exploration of these important issues can occur.
Case studies are representative of actual case submissions. Error descriptions may have been
modified for clarity.
Section 1
Medication Errors Originating in Outpaient Surgery (OPS)
Causes of Medication Errors______________________________________ 20
Table 1-1. Distribution of Outpatient Surgery Records
by Error Category Index....................................................................................3
Findings...........................................................................................................20
Medication Error Reporting_______________________________________ 5
Findings.............................................................................................................5
Table 1-2. Comparison of Medication Errors in
Outpatient Surgery by Population.....................................................................6
Table 1-3. Example of Medication Error Requiring
Life Sustaining Intervention...............................................................................7
Node of the Medication Use Process_ _______________________________ 8
Findings.............................................................................................................9
Table 1-4. Node Associated with Outpatient Surgery Records........................9
Types of Medication Errors_______________________________________ 10
Findings...........................................................................................................11
Table 1-5. Types of Errors Associated with
Outpatient Surgery Records............................................................................12
Cross-Tabulations—Types of Error by Error Category Index_ __________ 13
Table 1-6. Cross-tabulation of Types of Error Comparing
Non-Harmful and Harmful, All Records, Outpatient Surgery..........................14
Non-Harmful and Harmful, Pediatric Records, Outpatient Surgery_ ____ 15
Non-Harmful and Harmful, Adult Records, Outpatient Surgery.....................16
Non-Harmful and Harmful, Geriatric Records, Outpatient Surgery................17
Case Vignettes Group 1: Leading Types of
Errors for Outpatient Surgery Records...........................................................18
Table 1-10. Leading Causes of Outpatient Surgery
Medication Errors by Records Overall and by Population..............................22
Case Vignettes Group 2: Leading Causes
of Errors from Outpatient Surgery Records....................................................23
Factors Contributing to Medication Errors__________________________ 25
Findings...........................................................................................................25
Table 1-11. Contributing Factors Associated
with Outpatient Surgery Records....................................................................26
Case Vignettes Group 3: Leading Contributing
Factors from Outpatient Surgery Records......................................................27
Actions taken following Medication Errors__________________________ 29
Findings...........................................................................................................29
Table 1-12. Actions Taken as a Result of the Error, Outpatient Surgery......30
Products Involved in Medication Errors____________________________ 31
Findings...........................................................................................................31
Table 1-13. Most Commonly Reported Products Involved in
All Medication Errors Overall in Outpatient Surgery by
Patient Population...........................................................................................33
Table 1-14. Most Commonly Reported Products Involved in
Harmful (Categories E–I) Medication Errors in Outpatient
Surgery and by Patient Population.................................................................34
Table 1-15. Leading Type of Error and Leading Products............................36
Error Result on Level of Patient Care_ _____________________________ 37
Findings...........................................................................................................37
Table 1-16. Level of Care Rendered as a Result of the Error.........................38
Summary of Outpatient Surgery Medication Errors_ _________________ 39
section 1 << 15
section 1
Background_ ___________________________________________________ 3
Background
section 1
I
n 1980, Congress changed the Medicare reimbursement policies to favor
ambulatory surgery clinics and care in non-inpatient settings.1 Coupled
with innovations in surgical technology, improved anesthesia and pain management, and increasing pressure to control costs through shortened hospital stays,
the volume of procedures performed in ambulatory settings has grown steadily,
with more than three-quarters of all medical procedures now being performed
as outpatient surgeries.2 To accommodate this growth, many hospitals and
health systems now have outpatient departments as part of the entrance point
in the perioperative continuum of care. The Outpatient Surgery department is
a specialized setting within a hospital focusing on the patient’s registration and
pre-procedural/pre-operative screening processes. There is a diverse range of
pre-surgical activities conducted in this area in a timely manner for a diverse
range of patients by age, diagnosis, and care needs. Following the procedure/surgery, patients either return to the outpatient department for additional
recovery and are later released, or are admitted to the hospital for overnight
care.
For MEDMARX, the term Outpatient Surgery (a selection from the Location
field) is synonymous with same day surgery, day surgery, or ambulatory surgery centers associated with acute care facilities; and it designates the clinical
location where the error originates. This report does not examine outpatient
errors from free standing surgical centers. Nor does this report examine errors
originating in endoscopy/GI (gastroenterology) labs, as those would be assigned
to the pick list selection Endoscopy/GI Laboratory.
Medication Error Reporting
Error detection and reporting are the requisite first steps in learning more
about the nature of adverse events.3 The concept, “Detection Sensitivity
Level” (DSL), which began in transfusion medicine, describes the number of
patient safety events containing actual or unintended hazards. A high DSL
is desirable because errors not detected carry the potential for serious consequences. Furthermore, the opportunities to learn from failures are greater
than the opportunities to learn from successes.4 Higher reporting rates drive
a higher DSL, ultimately resulting in a decrease in harmful events as measured
by the error severity level. Patient safety leaders recognize DSL as an important indicator for inclusion in patient safety research. Patient safety leader s
also acknowledge that underreporting of errors hampers the opportunities to
improve the healthcare system.
A medication error reporting program should be a vital component of an
organization’s overall patient safety plan. Such a program should have sufficient
robustness to garner data across all error categories to determine the magnitude
of errors. Analyzing errors in the non-harmful category (Category B) should
include the institutional safety actions that were effective in preventing those
events from reaching the patient or what existing procedures were not followed
and that should be modified. Analysis of errors that reached the patient and
resulted in harm provides an opportunity to examine where additional safeguards should be implemented to prevent future harmful errors.
Findings
Between September 1, 1998, and August 31, 2005, there were 422 facilities
reporting errors in Outpatient Surgery. The majority of these facilities were
non-federal community hospitals with slightly more than half having less than
200 beds (Technical Appendix 1). Collectively, these facilities submitted 3,427
records with 2.9% (n = 99) reported as harmful (Tables 1-1 and 1-2). Of the
nine possible outcomes, errors involved only seven categories, as there were no
reports of permanent harm or death (Category G or I). Of the 3,427 records,
84 cases involved pediatric patients, 1,081 involved adult patients, and 606
Table 1-1. Distribution of Outpatient Surgery Records by Error Category Index
Error
Category
Result of Error
Number of
Errors
n=3,427
% of Total
100
Actual Errors
Categories B - I
n=3,138 (91.6%)
No Error
Category A
Circumstances or events that have the
capacity to cause error
289
8.4
Number of
Errors
An error occurred but the error did not reach
the patient
1,065
31.1
1,065
% of B-I
Errors that Reached
the Patient
Categories C - I
n=2,073 (60.5%)
Error, No Harm
33.9
Number of
Errors
% of C-I
Errors that Reached the
Patient and may have
Contributed to or Resulted
in Harm or Fatality
Categories E - I
n=99 (2.9%)
Category C
An error occurred that reached the patient
but did not cause patient harm
1,702
49.7
1,702
54.2
1,702
82.1
Category D
An error occurred that reached the patient
and required monitoring to confirm that it
resulted in no harm to the patient and/or
required intervention to preclude harm
272
7.9
272
8.7
272
13.1
76
2.2
76
2.4
76
3.7
76
76.8
20
0.6
20
0.6
20
1
20
20.2
Number of
Errors
% of E-I
Error, Harm
Category E
An error occurred that may have contributed
to or resulted in temporary harm to the
patient and required intervention
Category F
An error occurred that may have contributed to or resulted in temporary harm to
the patient and required initial or prolonged
hospitalization
Category G
to or resulted in permanent patient harm
0
0
0
0
0
0
0
0
Category H
An error occurred that required intervention
necessary to sustain life
3
0.1
3
0.1
3
0.1
3
3
Error, Death
Category I
to or resulted in the patient’s death
0
0
0
0
0
0
0
0
Adopted from the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
section 1 << 17
section 1
Category B
Table 1-2. Comparison of Medication Errors in Outpatient Surgery by Population
All Records
section 1
Error
Category
Index
n
Pediatric
%
n
Adult
%
n
Geriatric
%
n
Age not Provided
%
n
%
A
289
8.4
0
0
0
0
0
0
289
17.5
B
1,065
31.1
0
0
0
0
0
0
1,065
64.3
C
1,702
49.7
67
79.8
879
81.3
498
82.2
258
15.6
D
272
7.9
14
16.7
147
13.6
77
12.7
34
2.1
E
76
2.2
2
2.4
44
4.9
23
3.8
7
0.4
F
20
0.6
1
1.2
11
1
6
0.9
2
0.1
G
0
0
0
0
0
0
0
0
0
0
H
3
0.1
0
0
0
0
2
0.3
1
0.1
I
0
0
0
0
0
0
0
0
0
0
Total
Records
3,427
Percent
Harmful
84
2.9
1,081
3.6
606
5.9
1,656
5
* For Categories A & B, age is not required. For Categories C – I, age was not entered.
Table 1-3. Example of Medication Error Requiring Life Sustaining Intervention
Generic Name
Fentanyl
Description of Medication Error
For a procedure being performed in on an outpatient patient surgery unit involving an elderly female (> 85
years), a physician gave a verbal order for fentanyl 100 micrograms and midazolam 1 mg, which was confirmed
by the registered nurse. The medications were intermittently administered over a period of 8 minutes. At 11
minutes, the patient was nonresponsive and required naloxone and supplemental oxygen.
0.6
risk of a medication error. Active and latent failures are present in the MUP
and associating the medication error with its origin in the MUP allows for targeted interventions.
cases involved geriatric patients. These three populations had little percentage
difference between errors that did not result in harm (Category C or D). As a
percentage, more errors resulting in harm (Categories E–I) were seen in the
adult (5%) and geriatric (5.9%) population compared to the pediatric population (3.6%). Temporary harm (Category E) was seen in the majority of cases
with harmful outcome. Two of the three errors requiring life-sustaining interventions occurred in geriatric patients and summary of one case is presented
(Table 1-3).
The medication use process (MUP) is a multi-disciplinary process with six
unique phases (i.e., Procurement, Prescribing, Documenting/Transcribing,
Dispensing, Administering, and Monitoring).5 Each phase has both structures
and processes associated with professional responsibilities that minimize the
One such targeted intervention for errors originating in the Prescribing Node
has been the use of Computerized Prescriber Order Entry (CPOE). This technology has been effective at reducing errors7 in the inpatient setting and in
integrated outpatient settings. The success of the technology has been the inte-
Table 1-4. Node Associated with Outpatient Surgery Records
All Records
Pediatric
Adult
Geriatric
Age not Provided*
Node
n
%
n
%
n
%
n
%
n
%
Procurement
1
0
0
0
1
0.1
0
0
0
0
Prescribing
928
29.6
11
13.1
127
11.7
71
11.7
719
52.6
Transcribing/
Documenting
358
11.4
9
10.7
100
9.3
59
9.7
190
13.9
Dispensing
261
8.3
4
4.8
88
8.1
53
8.7
116
8.5
1,562
49.8
60
71.4
756
69.9
417
68.8
329
24.1
28
0.9
0
0
9
0.8
6
1
13
1
Administering
Monitoring
Total
3,138
84
1,081
606
1,367
Node is not applicable to Category A records
Population C-I data
section 1 << 19
section 1
Node of the Medication Use Process
Current patient safety management encourages organizations to examine processes for sources of risks and hazards.3 James Reason, a leading investigator
in error research, indicates that there are two categories of failure embedded
in processes.6 Active failures, involving individuals in direct contact with a
process, stem from the actions of individuals, and, as such, are human errors.
Latent failures are those created by organizational actions, culture, and decisions and are termed system errors. Adverse events, as Reason points out, are
the result of the interactions between active and latent failures.6
section 1
gration of data, including the medication orders, the current laboratory results,
and the patient’s history of allergies or co-morbid conditions. The Outpatient
Surgery setting may present a challenge to fully recognize the potential of
CPOE, given that physicians often see outpatients in a private setting and that
may not be connected to the hospital’s CPOE system. Pre-operative radiology
and laboratory testings may be performed in locations not affiliated with where
the surgery or procedure is planned. Finally, some patients may arrive just
prior to the scheduled procedure and their history not immediately available
for review. Together, these common issues in outpatient care pose significant
challenges for this form of technology to work in this environment.
For errors occurring during the Administering Node, many of the drugs may
not be prepared (or reviewed) by pharmacy but rather are prepared by the
nurse on the unit, thus by-passing an important safety check, the pharmacist.
The relatively low percentage of Dispensing Node errors may signal the lack
of fully integrating pharmacy’s professional role in this clinical setting. In
addition, there is a limited number of drugs utilized and stocked in this area.
Unusual drug order requests would typically be handled through the pharmacy
department, thus allowing pharmacy oversight of that particular order.
Findings
Based on actual medication errors (Categories B–I; n = 3,138), the largest percentage of all OPS errors (49.8%) originated in the Administering Node (Table
1-4). The majority of errors in the pediatric, adult, and geriatric populations
originated in the Administering Node, but at higher percentages (approximately 70%). The Prescribing Node was associated with the second highest
percentage of OPS errors; but in this node, pediatric, adult, and geriatric errors
were less than the overall pattern of 29.6%. Given these differences, errors that
originate in the Prescribing Node are intercepted before reaching the patient.
Errors originating in the Dispensing Node were present in less than 9% of the
events reported and Monitoring Node errors accounted for less than 1%. A
listing of the comparative findings appears in Section 5.
Types of Medication Errors
The Type of Error field is a multi-select field used to characterize or describe
how the medication error manifests itself, regardless of the cause(s). Some
authors have reported that Prescribing errors are the most common type of
error.8 The act of prescribing requires both cognitive functions and mechanical functions. The mechanical piece can include omitting important information or providing the wrong information. A Prescribing error originates in
the Prescribing Node and occurs when the prescriber fails to in either or both
of those processes, such as failure to complete an order (e.g., omits the dosage
form or duration), or when the prescriber writes an order that is contradictory (e.g., for an antimicrobial agent for which the patient is allergic to), or
when the prescriber orders an inaccurate dose (e.g., 100 mg rather than 10 mg).
Other studies suggest that errors most often involve an Improper dose/quantity
(wrong amount) or an Omission.9, 10
Omitting pre-procedural antimicrobial products has been linked to surgical site
infections.11 Antimicrobial prophylaxis, such as cefazolin, initiated prior to
the procedure has been shown to reduce surgical wound infections, especially
when administered up to one hour before surgical incision. Omitting preoperative benzodiazepines (e.g., midazolam) may alter planned approaches for
anesthesia. Anesthesia providers may administer the agent in the pre-operative
holding area or the patient may require extra induction agents at the time the
surgery begins.
Pediatric patients are at higher risk of a medication error involving an
Improper dose/quantity (wrong amount) than geriatric patients or patients
taken as a whole. Medication use in children is particularly error-prone due
to variations in dosing, ages, weights, and the drug formulations that must be
considered.12-15 Additional aspects that influence error outcomes include the
pharmacodynamic and pharmacokinetic properties associated with the products in light of children’s physiology. The decreased communication abilities
(developmental differences) of children is also a factor in hindering the identification of risk for injuries associated with medications12 or a factor in underdosing of pain medication.
Geriatric patients are susceptible to medication errors due to changes in renal
and hepatic function as well as changes in muscle mass, plasma protein levels,
and co-morbid conditions.16 The increasingly large number of medications
taken by geriatric patients places an extra burden on healthcare professionals
Table 1-5. Types of Errors Associated with Outpatient Surgery Records All Records
Type of Error
Pediatric
Adult
Geriatric
Age not Provided*
%
n
%
n
%
n
%
n
%
Prescribing error
892
27.7
6
7.3
95
9
53
9.2
738
47.8
Omission error
761
23.6
23
28
361
35.5
188
32.5
189
12.2
Improper dose/quantity
633
19.6
29
35.4
129
12.7
85
14.7
390
25.3
Unauthorized/wrong drug
461
14.3
9
11
183
18
107
18.5
162
10.5
Wrong time
206
6.4
5
6.1
91
8.9
46
7.9
64
4.1
Drug prepared
incorrectly
131
4.1
4
4.9
42
4.1
36
6.2
49
3.2
Wrong patient
116
3.6
1
1.2
36
3.5
17
2.9
62
4
Extra dose
99
3.1
4
4.9
56
5.5
21
3.6
18
1.2
Wrong administration technique
92
2.9
2
2.4
31
3
31
5.4
28
1.8
Wrong route
73
2.3
2
2.4
37
3.6
22
3.8
12
0.8
Wrong dosage form
69
2.1
0
0
7
0.7
8
1.4
54
3.5
Expired product†
11
0.3
0
0
4
0.4
0
0
7
0.5
Mislabeling†
8
0.2
0
0
1
0.1
0
0
7
0.5
Deteriorated product†
7
0.2
0
0
3
0.3
1
0.2
3
0.2
Number of Selections
3,559
85
1,076
615
1,783
Number of Records
3,223
82
1,018
579
1,544
† Selection not available all years
section 1 << 21
section 1
n
managing their care. This burden is translated to the ambulatory care staff
when caring for seniors and attempting to identify the various drugs that could
cause problems during procedures/operations being performed and the possibilities of adverse reactions or drug-drug interactions.
section 1
Findings
Cross-Tabulations – Types of Error by Error Category Index
Rather than examine types of errors by raw numbers of occurrence, a more
meaningful way to investigate risk in the various populations includes the use
of cross-tabulation analyses incorporating the severity of the error. Utilizing
the cross tabulation approach as an adjunct to overall occurrences supports
prioritization for quality improvement purposes. While overall counts may
highlight “high volume” areas to target, the cross- tabulation approach may
reveal a different pattern of relative risk.
At least one Type of Error was identified in 3,223 Outpatient Surgery records
(Table 1-5). For all errors, four selections (Prescribing error, Omission error,
Improper dose/quantity, and Unauthorized/wrong drug) were reported in the
majority (85.2%) of the events. This finding was also evident in the pediatric
(81.7%), adult (75.2%), and geriatric (74.9%) populations as well. The most
common selection for all records was Prescribing error and
was present in 27.7%. A prescriber error results when the
Table 1-6. Cross-tabulation of Types of Error Comparing Non-Harmful
order in incomplete (e.g., missing the dose), incorrect, or
and Harmful, All Records, Outpatient Surgery
inappropriate for the patient (i.e., ordering penicillin for
a patient with a pre-existing allergy). Some of the errors
Non-harmful
Harmful
resulted from the use of preprinted order forms, where the
Type of Error
n
%
n
%
prescriber failed to change antimicrobial therapy when the
86
93.5
6
6.5
patient had a pre-existing allergy. Other prescribing errors
Wrong dosage form
66
95.7
3
4.3
occurred when the prescriber had inadequate information
(such as a child’s weight). As a percentage, Prescribing
443
96.1
18
3.9
errors were reported more often in all OPS records versus
Wrong time
199
96.6
7
3.4
any other population studied.
Errors involving an Improper dose/quantity occurred in
35.4% (one-third) of the pediatric errors, compared to 19.6%
of all records, 12.7% in the adult records, and 14.7% of geriatric records. Unauthorized/wrong drug errors had the
highest percentage of occurrence in the geriatric population
(18.5%) compared to all errors (14.3%) and pediatric errors
(11%). Less commonly reported, but still of clinical significance, are errors involving Wrong patients, Extra doses,
Wrong administration technique, and Wrong dosage forms.
The comparative findings appear in Section 5.
612
96.7
21
3.3
Wrong route
71
97.3
2
2.7
Prescribing error
872
97.8
20
2.2
Wrong patient
114
98.3
2
1.7
Drug prepared incorrectly
129
98.5
2
1.5
Extra dose
98
99
1
1
Omission error
754
99.1
7
0.9
7
100
0
0
Expired product†
11
100
0
0
Mislabeling†
8
100
0
0
Data drawn from 3,559 Type of Error selections contained within 3,223 records
Table 1-7. Cross-tabulation of Types of Error Comparing Non-Harmful and Harmful, Pediatric Records, Outpatient Surgery
Pediatric Records
Non-harmful
Harmful
Type of Error
n
%
n
%
26
89.7
3
10.3
4
100
0
0
Extra dose
4
100
0
0
23
100
0
0
6
100
0
0
9
100
0
0
2
100
0
0
Wrong patient
1
100
0
0
Wrong route
2
100
0
0
Wrong time
5
100
0
0
section 1
Omission error
Prescribing error
Table 1-8. Cross-tabulation of Types of Error Comparing Non-Harmful and Harmful, Adult Records, Outpatient Surgery
Adult Records
Non-Harmful
Harmful
Type of Error
n
%
n
%
Wrong dosage form
6
85.7
1
14.3
Prescribing error
85
89.5
10
10.5
120
93
9
7
29
93.5
2
6.5
173
94.5
10
5.5
Wrong route
35
94.6
2
5.4
Wrong time
87
95.6
4
4.4
Wrong patient
35
97.2
1
2.8
41
97.6
1
2.4
Extra dose
55
98.2
1
1.8
Omission error
356
98.6
5
1.4
3
100
0
0
Expired product†
4
100
0
0
section 1 << 23
Table 1-9. Cross-tabulation of Types of Error Comparing Non-Harmful and Harmful, Geriatric Records, Outpatient Surgery
Causes of Medication Errors
section 1
Geriatric Records
Non-Harmful
Harmful
Type of Error
n
%
n
%
Prescribing error
45
84.9
8
15.1
Wrong dosage form
7
87.5
1
12.5
28
90.3
3
9.7
100
93.5
7
6.5
Wrong time
43
93.5
3
6.5
80
94.1
5
5.9
Wrong patient
16
94.1
1
5.9
35
97.2
1
2.8
Omission error
187
99.5
1
0.5
1
100
0
0
Extra dose
21
100
0
Wrong route
22
100
0
Data based on 615 selections contained within 579 records
Findings
For all OPS records, 2.9% of the reports were associated with harmful events
(Table 1-2). When performing a cross-tabulation of these records, five types
of errors exceeded this threshold, with Wrong administration technique
errors having the largest proportion of harmful events (6.5%). In the pediatric
records, only one type of error, Improper dose/quantity was associated with
harmful events (10.3%). For adult errors, six various types of errors exceeded
the threshold of 5.1%. Wrong dosage form and Prescribing errors the two
types with the highest percentage of harmful events. Finally, in the geriatric
records, seven type of error selections exceeded the threshold of 5.1%. In this
population, the selection Prescribing error was ranked first, which is aligned
with the overall findings (Tables 1-6, 1-7, 1-8, and 1-9).
Medication errors rarely occur as the result of a single
cause. Instead, medication errors are often the result
of multiple causes. There are 69 causes of error available in the MEDMARX pick list. The field is a multiple
select field, indicating that more than selection may
be associated with the same record. The selection,
Performance deficit, describes an error’s occurrence
even when the person involved in the error had the requisite knowledge, skills, and abilities to safely perform
the task, but failed to do so successfully. Procedure/
protocol not followed can be attributed to lack of familiarity with awareness of existing procedures and/or protocols for specific treatments.
Patient allergy information is a critical component of
medication safety and eliminating known drug allergy
0
errors should be an easily attainable goal. Information
technology, such as computerized prescriber order
entry with clinical decision support and appropriate
alert systems, offers the best approach for accomplishing this goal and reducing iatrogenic injury.7
Deploying this technology in the Outpatient Surgery setting presents a challenge, as many patients arrive with hand-written orders on the day of the
procedure. Introducing new technology solutions has been shown to alter the
error patterns, rather than eliminating errors entirely. Therefore, practitioners
should be aware of the potential of introducing new errors into a busy workplace. Patients should be encouraged or required to pre-register prior to the
scheduled day of the procedure especially since outpatient settings lack integration between physician preferences, pharmacy oversight, and the Outpatient
Surgery department.
0
Findings
For all Outpatient Surgery medication error records, four selections
(Performance deficit, Procedure/protocol not followed, Communication, and
Case Vignettes Group 1: Leading Types of Errors for Outpatient Surgery Records
section 1
section 1 << 25
section 1
Case Vignettes Group 1: Leading Types of Errors for Outpatient Surgery Records
Table 1-10. Leading Causes of Outpatient Surgery Medication Errors by Records Overall and by Population
All Records
Cause of Error
Pediatric
Adult
Geriatric
Age not Provided*
%
n
%
n
%
n
%
n
%
40.8
34
42.5
524
50.6
298
50.2
498
46.8
Procedure/protocol not
followed
778
23.5
18
22.5
318
30.7
193
32.5
249
23.4
Communication
518
15.6
21
26.3
202
19.5
120
20.2
175
16.4
Knowledge deficit
364
11
7
8.8
80
7.7
56
9.4
221
20.8
Documentation
339
10.2
8
10
107
10.3
51
8.6
173
16.2
Contraindicated, drug
allergy
322
9.7
4
5
71
6.9
24
4
223
20.9
Computerized prescriber
order entry†
201
6.1
0
0
5
0.5
1
0.2
195
18.3
Written order
169
5.1
4
5
50
4.8
26
4.4
89
8.4
Transcription inaccurate/
omitted
157
4.7
7
8.8
35
3.4
30
5.1
85
8
Abbreviations
144
4.3
1
1.3
1
0.1
4
0.7
138
13
Knowledge deficit) comprised nearly 91% of the Cause of Error selections
(Table 1-10). Another selection, Contraindicated, drug allergy occurred in
9.7% of the all OPS records, a finding not present in the same magnitude across
the three patient populations.
There was minor variation in the leading causes of errors in the pediatric population. The percentage with the selection Communication was 11 points higher
than records overall. The selection Calculation error was 7 percentage points
higher.
Mistakes in calculations have long been identified as leading causes for pediatric medication errors.12 The high percentage of pediatric records identifying
Calculation error as a Cause of Error points to an area where standardized
concentrations will lead to requisite changes in practice. The vast majority of
healthcare providers demonstrated math proficiency during their academic
experience; however, it is the episodic failure in the calculation process that
threatens patient safety. Until universal acceptance of the metric system, clinical documentation forms should reflect a patient’s weight in kilograms and all
forms should be standardized and the weight highly visible. Eliminating the
expression of weight in pounds by pediatric departments may also help reduce
the possibility of errors when calculating doses in prescribing or administering medications. Every Outpatient Surgery unit should have ready access to
standardized weight conversion charts or pocket references to eliminate manual
calculations. Independent double-checks of medication dosages is warranted to
confirm accuracy of all calculations.
Also in the adult patients, the three leading selections mirrored OPS errors
overall with slight variations in the percentages of occurrence. Finally, while
the percentage of records associated with preprinted order forms is slight
(about 3%), this finding is higher than the general overall pattern associated
section 1 << 27
section 1
n
1,354
Performance deficit
section 1
Case Vignettes Group 2: Leading Causes of Errors from Outpatient Surgery Records
Table 1-11. Contributing Factors Associated with Outpatient Surgery Records
All Records
Contributing Factor
Pediatric
Adult
Geriatric
Age not Provided*
n
%
n
%
n
%
n
%
n
%
None
544
43.1
17
51.5
189
37.1
106
36.3
232
54.3
Distractions
364
28.9
11
33.3
162
31.8
95
32.5
96
22.5
Staff, inexperienced
115
9.1
1
3
53
10.4
24
8.2
37
8.7
Workload increase
105
8.3
3
9.1
46
9
30
10.3
26
6.1
70
5.6
1
3
32
6.3
15
5.1
22
5.2
No access to patient information
41
3.3
0
0
13
2.6
14
4.8
14
3.3
Staffing, insufficient
41
3.3
0
0
16
3.1
9
3.9
16
3.7
Patient transfer
41
3.3
0
0
22
4.3
12
4.1
7
1.6
Emergency situation
15
1.2
0
0
4
0.8
4
1.4
7
1.6
Shift change
19
1.5
0
0
10
2
7
2.4
2
0.5
Staff, floating
17
1.3
0
0
10
2
2
0.7
5
1.2
No 24-hour pharmacy
11
0.9
0
0
6
1.2
5
1.7
0
0
Staff, agency/temporary
13
1
1
3
6
1.2
5
1.7
1
0.2
Imprint, identification failure
13
1
0
0
4
0.8
3
1
6
1.4
Staffing, alternative hours
7
0.6
0
0
4
0.8
3
1
0
0
Patient names similar/same
7
0.6
1
3
4
0.8
0
0
2
0.5
Poor lighting
4
0.3
0
0
1
0.2
1
0.3
2
0.5
Computer System/Network down
4
0.3
0
0
1
0.2
0
0
3
0.7
Code situation
2
0.2
0
0
1
0.2
0
0
1
0.2
Range orders
1
0.1
0
0
1
0.2
0
0
0
0
1,434
35
585
335
479
Number of Records
1,261
33
509
292
427
section 1 << 29
section 1
Cross coverage
preprinted order forms (1%). The comparative findings appear in Technical
Appendix 5.
The majority of the Contributing Factor selections for OPS errors are associated with fewer than 10% of the records, a finding that carried through in the
pediatric population and the geriatric population. The comparative findings
appear in Technical Appendix 6.
Factors Contributing to Medication Errors
section 1
Contributing Factors are situational (e.g., workload increase), environmental
(e.g., lighting insufficient), and/or organizational (e.g., staffing insufficient)
influences that affect the occurrence of medication errors.
They differ from the causes of error because they do not directly lead to an
error. Based on this distinction, Contributing Factors appear to be underreported, recorded, or not entirely understood. Situational and environmental
factors are time-limited and may be difficult to predict. Organizational factors are the result of latent conditions imposed by others not directly involved
in the medication error event. Such “failures” may be so common that they
are woven into the fabrics of healthcare in such a way that healthcare workers fail to recognize or distinguish them from normal duties.17 According to
Hammons, et al., 2 most ambulatory care is technologically less complex than
inpatient care but logistically more complex. The outpatient setting provides
minimal support for coordinating and managing care but requires more communication among clinicians (who may be at different sites), patients, and
families. More handoffs and transitions of care are present in Outpatient
Surgery than in many other clinical areas. Institutions should view this data as
an opportunity to address contributing factors through policies and procedures.
Findings
The Contributing Factors field and its corresponding 20-item multi-select pick
list became mandatory in 2003. Given this change in the MEDMARX program,
only slightly more than one third (37.5% or n = 915) of the Outpatient Surgery
records were associated with at least one selection. The majority of all records
had the selection None or Distractions as contributing to the error (Table 111). Six Contributing Factor selections serve as proxy measures for the impact
of staff work patterns associated with these medication error events: (a) Cross
coverage; (b) Staff, agency/temporary; (c) Staff, floating; (d) Staff, inexperienced; (e) Staffing, alternative hours; and (f) Staffing, insufficient.
Actions taken following Medication Errors
Actions taken as a direct result of an error are a measure of how seriously an
organization responds to errors. Patient safety is advanced by understanding
and reinforcing provider’s ability to detect and report errors.17 Additionally,
patient safety is advanced by identifying and mitigating the hazards associated
with the medication use process. An organization’s culture, through the actions
of its managers, significantly influences what happens after an event. Today’s
patient safety programs must ensure that all actions taken have lasting effects
on the practice environment. It requires effort on the part of managers to
establish effective methods for action following a medication error. Procedures
should be reviewed and all practitioners involved in the error should have the
opportunity to react and provide input into appropriate actions and procedures
to benefit the patient and assure that this type of error does not occur again.
Ideally, actions taken are aimed at “fixing the system” and may not be immediately discernible at the time the error was reported. As reporting programs
mature and continue to collect such information, practitioners are encouraged
to update records that reflect a link between system changes and all records that
were studied in the trend. In this manner, the interventions can be judged for
their effectiveness.
Findings
Approximately 47.5% of the records (n=1,631) documented an action taken
as a direct result of the error (Table 1-12). The four most commonly reported
selections (Informed staff who made the initial error, Communication process
enhanced, Education/Training provided, Informed staff who was also involved
in error) were essentially the same for all records, pediatric records, and geriatric records.
Case Vignettes Group 3: Leading Contributing Factors from Outpatient Surgery Records
section 1
section 1 << 31
Table 1-12. Actions Taken as a Result of the Error, Outpatient Surgery
All Records
section 1
Action Taken
Pediatric
Adult
Geriatric
Age not Provided*
n
%
n
%
n
%
n
%
n
%
Informed staff who made
the initial error
906
55.5
30
60
323
52.9
225
60.8
328
54.7
Communication process
enhanced
319
19.6
7
14
125
20.5
76
20.5
111
18.5
Education/Training provided
317
19.4
9
18
128
20.9
78
21.1
102
17
Informed staff who was also
involved in error
307
18.8
8
16
129
21.1
82
22.2
88
14.7
Informed patient’s physician
200
12.3
8
16
97
15.9
54
14.6
41
6.8
None
127
7.8
4
8
49
8
22
5.9
52
8.7
Informed patient/caregiver
of medication error
88
5.4
3
6
40
6.5
23
6.2
22
3.7
Policy/Procedure changed
32
2
0
0
15
2.5
9
2.4
8
1.3
Staffing practice/policy
modified
26
1.6
0
0
10
1.6
9
2.4
7
1.2
Environment modified
22
1.3
2
4
11
1.8
2
0.5
7
1.2
Policy/Procedure instituted
17
1
0
0
3
0.5
7
1.9
7
1.2
Computer software
vmodified/obtained
10
0.6
1
2
2
0.3
0
0
7
1.2
2
0.1
0
0
1
0.2
0
0
1
0.2
Formulary changed
2,373
72
933
587
781
Number of Records
1,631
50
611
370
600
Products Involved in Medication Errors
In recent years, the Joint Commission’s National Patient Safety Goals have
explicitly identified the need to improve the use of all medications by developing safe practices for products used in patient care. Each facility should
identify problems that pre-dispose patients to error or harm. One way is to
examine the products associated with errors is to review the most common
types of errors and the most commonly reported products associated with the
errors. Further analysis can assist practitioners in developing safety interventions around specific types of errors and specific products. This approach also
supports the evaluation of the entire medication use process, from prescribing through monitoring. In Outpatient Surgery special attention may need to
include how medications are obtained and stored on the unit.
Table 1-13. Most Commonly Reported Products Involved in All Medication Errors Overall in Outpatient Surgery by Patient Population
All Records Products-Generic Name n
%
Cefazolin
488
14.7
Midazolam†
100
3.0
Morphine*†
96
2.9
Hydrocodone and Acetaminophen
90
2.7
Vancomycin
82
2.5
Meperidine†
77
2.3
Oxycodone and Acetaminophen
76
2.3
Levofloxacin
66
2.0
Gentamicin
61
1.8
Ciprofloxacin
57
1.7
Cefotetan
56
1.7
Ketorolac
54
1.6
Ampicillin
51
1.5
Phenylephrine* 50
1.5
Fentanyl*†
48
1.4
%
Cefazolin
488
14.7
Midazolam†
100
3.0
Morphine*†
96
2.9
90
2.7
Vancomycin
82
2.5
Meperidine†
77
2.3
76
2.3
Levofloxacin
66
2.0
Gentamicin
61
1.8
Ciprofloxacin
57
1.7
Cefotetan
56
1.7
Ketorolac
54
1.6
Ampicillin
51
1.5
Phenylephrine* 50
1.5
Fentanyl*†
48
1.4
%
Cefazolin
488
14.7
Midazolam†
100
3.0
Morphine*†
96
2.9
90
2.7
Vancomycin
82
2.5
Meperidine†
77
2.3
76
2.3
Levofloxacin
66
2.0
Gentamicin
61
1.8
Ciprofloxacin
57
1.7
Cefotetan
56
1.7
Ketorolac
54
1.6
Ampicillin
51
1.5
Phenylephrine* 50
1.5
Fentanyl*†
48
1.4
Based on 2,979 records, 3,323 selections, and 323 unique products
Based on 78 records, 80 selections,
and 25 unique products
Based on 1,006 records, 1,123 selections and 204 unique products
Based on 571 records, 653 selections, and 133 unique products
† Denotes high-alert medication
* Includes all dosage forms and formulations
section 1 << 33
section 1
%
Cefazolin
488
14.7
Midazolam†
100
3.0
Morphine*†
96
2.9
90
2.7
Vancomycin
82
2.5
Meperidine†
77
2.3
76
2.3
Levofloxacin
66
2.0
Gentamicin
61
1.8
Ciprofloxacin
57
1.7
Cefotetan
56
1.7
Ketorolac
54
1.6
Ampicillin
51
1.5
Phenylephrine* 50
1.5
Fentanyl*†
48
1.4
section 1
Table 1-14
Table 1-15. Leading Type of Error and Leading Products.
Type of Error
Prescribing error
(Based on 823 records)
Omission error
Wrong time
n
Cefazolin
134
Morphine†*
41
Cefotetan
29
Docusate Sodium
24
Chlorhexidine Gluconate
22
Cefazolin
196
Levofloxacin
31
Midazolam†
20
Gentamicin
23
Vancomycin
20
Midazolam†
36
Cefazolin
35
Acetaminophen
20
20
Meperidine†
20
Cefazolin
38
22
Cyclopentolate
19
Phenylephrine
19
18
section 1
Product involved
Cefazolin
Vancomycin
Ciprofloxacin
Hydromorphone†
38
18
8
section 1 << 35
Findings
section 1
Between September 1, 1998, and August 31, 2005, there were 2,979 Outpatient
Surgery records associated with 3,323 product selections, indicating that some
medication error events involved more than one product (Table 1-13). These
records contained 323 unique product selections. For medication errors
involving the pediatric population that identified a product (n=78), there
were 25 unique product selections. In the adult population (n=1,006), there
were 204 unique products. For medication errors in the geriatric population
(n=571), there were 133 unique product selections.
In overall OPS records, cefazolin was identified as the product most often
involved in a medication error (n=488) and it represented 14.7% of all selections. Other antimicrobial products included vancomycin, levofloxacin, gentamicin, ciprofloxacin, cefotetan, and ampicillin. Other agents involved in errors
included Central Nervous System (CNS) medications such as the opioids (morphine, meperidine, and fentanyl).
In the pediatric medication error records, the CNS agent midazolam was implicated in one-quarter of the errors. As a percentage, midazolam errors in the
pediatric population (25%) out-paced midazolam errors in OPS errors overall
(3.0%), adult errors (2.8%), and geriatric errors (1.7%). Other CNS products
as well as antimicrobials were involved in the pediatric errors. In the adult
medication error records, the two leading antimicrobial agents reported were
cefazolin (17.6%) and vancomycin (2.7%). Errors with CNS products were
also common. Leading product selections involved in geriatric errors contained
several classes of medications, including antimicrobial agents (such as cefazolin), ophthalmic agents (such as cyclopentolate), and CNS medications (such as
meperidine).
During the study period, 87 records were determined to result in patient harm
and these records contained 52 unique products (Table 1-14). The most commonly reported products to result in harm were central nervous system drugs,
which were present in more than 30% of the selections. There were three pediatric records associated with harmful events, each identifying one specific narcotic agent. There were 51 adult errors involving 36 products, nearly one-third
of which were CNS agents. In the geriatric population, 29 records were associated with harm and implicated 23 different product selections. In this set, fentanyl and insulin were the two leading products associated with harm (9.7%).
Further analysis indicates that developing policies and procedures or conducting additional analyses around antimicrobials would address many of the
issues.
Antimicrobials play a significant role in the recovery of surgical patients.
Exposure to infection during surgery is especially relevant in the pediatric and
geriatric populations. Developing check lists and performing chart reviews
prior to the patient leaving the Outpatient Department may eliminate omission
errors.
Independent double checks of calculations for pediatric dosages should be
implemented to avoid over-dosing with central nervous system products.
Duplicate or conflicting medication orders must be resolved.
Error Result on Level of Patient Care
Medication errors impose increased demands for resources on healthcare facilities, adding to the total cost of healthcare. No recent studies have determined
the exact increase in costs as a result of medication errors, but early studies
have estimated the annual cost to exceed $2 billion.18 Even simple interventions, such as Observation initiated/increased, Vital signs monitoring initiated/increased consume resources; and, as stated previously the true costs of all
actions are not fully known or appreciated.
Facilities should investigate and make determinations on the level of care
rendered in response to an error to establish a baseline and assist the hospital administrators in evaluating patient care and costs associated with patient
safety activities.
Findings
The Error Result on Level of Patient Care is applicable to errors that reached
the patient (Categories
C– I). The majority of records (nearly 70%) indicated that no additional care
was rendered to the patient following the error (Table 1-16). About 27% of the
selections associated with pediatric records indicated Observation initiated/
increased, Vital signs monitoring initiated/increased, or Oxygen administered.
Table 1-16. Level of Care Rendered as a Result of the Error
All Records
Level of Care Selection
Pediatric
Adult
Geriatric
Age not Provided*
n
%
n
%
n
%
n
%
n
%
None
938
69.9
44
69.8
531
69
324
71.8
39
67.2
Drug therapy initiated/changed
168
12.5
6
9.5
105
13.6
51
11.3
6
10.3
Observation initiated/increased
155
11.5
12
19
93
12.1
45
10
5
8.6
60
4.5
3
4.8
36
4.7
20
4.4
1
1.7
33
2.5
1
1.6
19
2.5
12
2.7
1
1.7
Laboratory tests performed
27
2
0
0
10
1.3
16
3.5
1
1.7
Oxygen administered
13
1
2
3.2
6
0.8
5
1.1
0
0
Hospitalization, initial
14
1
1
1.6
7
0.9
6
1.3
0
0
Hospitalization, prolonged 1-5 days
7
0.5
1
1.6
4
0.5
2
0.4
0
0
Delay in diagnosis/treatment/surgery
41
3.1
1
1.6
20
2.6
15
3.3
5
8.6
Narcotic antagonist administered
8
0.6
0
0
4
0.5
4
0.9
0
0
Transferred to a higher level of care
8
0.6
0
0
5
0.6
3
0.7
0
0
Airway established/patient ventilated
2
0.1
0
0
2
0.3
0
0
0
0
X-ray, CAT, MRI, or other diagnostic
test(s) performed
2
0.1
0
0
1
0.1
1
0.2
0
0
CPR administered
1
0.1
0
0
1
0.1
0
0
0
0
1,477
71
844
504
58
These three selections, as percentages of error, were reported more often in
this population than in OPS errors overall or in the geriatric population. The
three selections associated with pediatric records, especially when paired with
the Type of Error (i.e., an Improper dose/quantity) and the specific product
involved (i.e., a midazolam) in the error reported, were deemed to be internally
consistent with anticipated findings and reflect appropriate actions by the staff.
For example, an excessive dose of a narcotic can lead to respiratory depression
requiring closer observation, vital signs, and oxygen.
Summary of Outpatient Surgery Medication Errors
section 1 << 37
section 1
Vital signs monitoring initiated/increased
Antidote administered
Outpatient Surgery departments intend to increase organizational efficiency
related to perioperative care. As shown, medication errors do occur in
Outpatient Surgery and threaten the efficiency of the organization and the
quality of patient care. This Report identifies and addresses recurring problems
that jeopardize patient safety in the Outpatient Surgery department. Priority
areas that USP has identified for further investigation are:
4 D
evising strategies around medications (such as midazolam or other controlled substances) that have a high risk for harm by understanding the
causes of these errors;
section 1
4 Adopting a culture of safety and error reporting;
4 Exploring the use of electronic health records to avoid loss of information;
4 R
eviewing preprinted orders to ensure appropriate clinical alternatives (e.g.,
in the case of allergies), and the appropriate use of abbreviations;
4 Reducing the reliance on verbal orders;
4 A
ddressing the influence of Contributing Factors (e.g., Distractions) that
may play a role in the medication error;
4 E
xpanding the pharmacy department’s role in perioperative care by having dedicated staff that participate in the medication use process, including
medication reconciliation and standardizing (or limiting) the products routinely available,
4 R
eviewing all institutionally developed labels for adequate font size and
permanency of ink (to avoid smears).
4 Expanding the use of bar-code medication administration systems;
4 E
mpowering patients to participate in pre-procedure safety activities, such
as preregistration, marking the surgical site, , providing history and physical
information, including current medications, allergies and participating in
medication reconciliation;
References
4 E
nsuring that patients and their corresponding chart forms are properly
identified;
2.
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR.
Ambulatory patient safety. What we know and need to know. Journal
Ambulatory Care Management. Jan-Mar 2003;26(1):63-82.
4 D
eveloping check lists that are accurately completed prior to patients leaving the area to minimize the loss of information through hand-offs;
1.
Winter A. Comparing the mix of patients in various outpatient surgery settings. Health Affairs. 2003;22(6):68-75.
4 D
eveloping strategies to ensure that medications are administered at the
correct time, especially antimicrobial agents;
3.
Battles JB, Lilford RJ. Organizing patient safety research to identify
risks and hazards. Quality and Safety in Health Care. Dec 2003;12 Supplement
2:ii2-7.
4 Implementing strategies that adequately identify and communicate allergy
information and other clinical information to all members of the perioperative team;
4.
Kaplan HS, Battles JB, Van der Schaaf TW, Shea CE, Mercer SQ.
Identification and classification of the causes of events in transfusion medicine.
Transfusion. Nov-Dec 1998;38(11-12):1071-1081.
4 Resolving duplicate or conflicting medication orders;
5.
Nadzam DM, ed. A systems approach to medication use. Oakbrook
Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations;
1998. Cousins DD, ed. Medication use: A systems approach to reducing errors.
4 E
xpanding the use of weight conversion charts and redesigning chart forms
to express patient’s weight in kilograms, such that the healthcare providers
can rapidly identify the correct the patient’s weight for use in clinical care;
4 E
nsuring that calculations are accurate throughout the medication use process, and by using an independent or technological double-check system
especially in the pediatric population;
6.
Reason J. Human error. New York City: Cambridge University; 1990.
7.
Bates DW. Using information technology to reduce rates of medication errors in hospitals. British Medical Journal. Mar 18 2000;320(7237):788791.
8.
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug
events and potential adverse drug events. Implications for prevention. ADE
Prevention Study Group. JAMA. Jul 5 1995;274(1):29-34.
9.
Hicks RW, Cousins DD, Williams RL. Summary of information submitted to MEDMARX in the year 2002. The quest for quality. Rockville, MD:
United States Pharmacopeia; 2003.
18.
Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events
in hospitalized patients. JAMA. Jan 22-29 1997;277(4):307-311.
a
10.
Hicks RW, Santell JP, Cousins DD, Williams RL. MEDMARXsm 5th
anniversary data report. A chartbook of 2003 findings and trends 1999-2003.
Rockville, MD: The United States Pharmacopeia Center for the Advancement
of Patient Safety; 2004.
section 1
11.
Mangram AJ, Horna TC, Pearson ML, Silver LC, Jarvis WR, The
Hospital Infection Control Practices Advisory Committee. Guideline for
prevention of surgical site infection, 1999. Infection Control and Hospital
Epidemiology. 1999;20:247-278.
12.
Kaushal R, Jaggi T, Walsh K, Fortescue EB, Bates DW. Pediatric medication errors: what do we know? What gaps remain? Ambul Pediatr. Jan-Feb
2004;4(1):73-81.
13.
Cowley E, Williams R, Cousins D. Medication errors in children: A
descriptive summary of medication error reports submitted to the United States
Pharmacopeia. Current Therapeutic Research. 2001;62(9):627-640.
14.
Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies
for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. Apr 2003;111(4):722-729.
15.
Kaushal R, Bates DW, Landrigan C, et al. Medication errors and
adverse drug events in pediatric inpatients. JAMA. Apr 25 2001;285(16):21142120.
16.
Kuchta A, Golembiewski J. Medication use in the elderly patient:
focus on the perioperative/perianesthesia setting. J Perianesth Nurs. Dec
2004;19(6):415-424; quiz 425-417.
17.
Cook RI, Render M, Woods DD. Gaps in the continuity of care and
progress on patient safety. British Medical Journal. Mar 18 2000;320(7237):791794.
section 1 << 39
section 1
Section 2
Medication Errors Originating in Preoperative Holding Area
Section 2: Medication Errors Originating in Preoperative Holding Area_ 1
Background.......................................................................................................3
Case Vignettes Group 5: Leading Causes of Errors from
Preoperative Holding Area Records................................................................16
Table 2-1. Distribution of Records by Error Category Index,
Preoperative Holding Area................................................................................3
Medication Errors in Preop Holding Area_ __________________________ 5
Table 2-7. Contributing Factors Associated with
Findings.............................................................................................................5
Findings...........................................................................................................18
Actions Taken following a Medication Error_ _______________________ 20
Table 2.3 Example of Medication Error Sentinel
Event in PreOp Holding Area............................................................................7
Table 2-8. Actions Taken as a Direct Result of the
Error for Preoperative Holding Area Records.................................................21
Medication Use Process___________________________________________ 7
Products Implicated in Medication Errors_ _________________________ 22
Findings.............................................................................................................8
Table 2-4. Node Associated with Preoperative Holding Area Records...........9
Types of Medication Errors_ _____________________________________ 10
Findings...........................................................................................................10
Table 2-5. Types of Errors Associated
with Preoperative Holding Area.......................................................................11
Case Vignettes Group 4: Leading Types of Errors from
Findings...........................................................................................................20
Findings...........................................................................................................22
Table 2-9. Most Commonly Reported Products Involved in Overall
(Categories A–I) Preoperative Holding Area Medication Errors......................23
Table 2-10. Harmful Medication Errors in Preoperative Holding Area
(All Records, Pediatric, Adult, and Geriatric)...................................................25
Table 2-11. Drill down by Leading Type of Error and
Leading Products............................................................................................26
Error Result on Level of Patient Care_ _____________________________ 27
Findings...........................................................................................................27
Findings...........................................................................................................14
Table 2-6. Leading Causes of Error in Preoperative Holding Area.................15
Summary of Preoperative Holding Area Medication Errors____________ 29
Sectiion 2 << 41
section 2
Table 2-2. Comparison of Severity of Medication Errors in
Preoperative Holding Area Records by Patient Population..............................6
Background
section 2
The Preoperative (Preop) holding area is an important but often overlooked
component in the continuum of perioperative care.1 This area is a transitional
place for patient holding while the operating room is being prepared.1 Once
just a staging area for patients prior to surgery, it has now become a specialized
area that contributes to positive experiences for patients and family members,
especially those attending a pediatric patient.2 The majority of surgical patients
and family members have their initial contact with members of the operating
room staff in the Preop holding area.
Procedures that occur in the Preop holding area include the initiation of
intravenous fluids, administration of preoperative medications, insertion of
hemodynamic monitoring lines, administration of regional anesthesia blocks,
and cardiac monitoring.2 Because of the various activities related to preparing
the patient for the surgical procedure, some patients have described this area
as impersonal, strange, and stressful thereby increasing the patient’s anxiety
level.1, 3 Addressing patients psycho-social and physical needs are embedded
in clinical practice in the Preop holding area.1
In many institutions, the Preop holding area is located near the operating room
(OR) and the post anesthesia care unit (PACU). In some institutions, however,
it is part of the OR and in some, part of the PACU.2 USP added Preoperative
holding area as a selection to the location pick list in 2003 as a result of this
area’s medication error potential. This section presents the findinTgs of 779
medication errors in the Preop holding area reported by 177 institutions. It
provides further granularity within the perioperative continuum about where
medication errors can originate.
Medication Errors in Preop Holding Area
Medication errors that originate in the Preop holding area can affect any
patient, regardless of age or clinical condition. Safety measures, including locking the transport bed, verifying patient identity, and confirming the anticipated
surgical procedure should be common practices in this setting. Other safety
measures include patient assessment in terms of the relevant health history,
physical status, vital signs, impairments, skin integrity, medication history,
preoperative orders, surgical site verification, and signed consent. If peripheral
nerve blocks are initiated in the pre-op area, measures must be in place to allow
an adequate “time out” procedure as a safety check. All relevant information
is then available for the surgical team.1 Recognizing medication safety in the
Preop holding area adds an extra dimension to current safety measures. As
the complexity of preoperative care delivered in this area increases, so does the
breadth of medications utilized. Patients will require additional monitoring to
determine whether the anticipated response to the medication is achieved.1 No
prior literature was found that discussed the occurrence of medication errors
originating in the Preop holding area.
Findings
Between March 14, 2003, and August 31, 2005, 177 facilities reported errors
in Preop holding. The majority of these facilities were non-federal general
community hospitals and had fewer than 200 beds (Technical Appendix 1).
Collectively, these facilities submitted 779 records with 2.8% (n = 22) reported
as harmful (Tables 2-1 and 2-2). Errors were involved in seven of nine possible
outcomes with no reports of permanent harm or death (Category G or I). Of
the 779 records, there were 24 reports involving pediatric patients, 239 involving adults, and 151 involving geriatric patients (Table 2-2). Harmful events
were associated with the grouping, all records (n = 11), pediatrics (n = 1), adult
(n = 17), and geriatric patients (n = 4). The highest percentage of harmful
errors involved adults (7.1%). There was one case where the error required life-
Table 2-1. Distribution of Records by Error Category Index, Preoperative Holding Area
section 2
section 2 << 43
Table 2-2. Comparison of Severity of Medication Errors in Preoperative Holding Area Records by Patient Population
All Records
section 2
Error Category Index
n
%
Pediatric
n
Adult
%
n
Geriatric
%
n
Age not Provided*
%
n
%
A
167
21.4
0
0
0
0
0
0
167
45.8
B
177
22.7
0
0
0
0
0
0
177
48.5
C
362
46.5
18
75
197
82.4
132
87.4
15
4.1
D
51
6.5
5
20.8
25
10.5
15
9.9
6
1.6
E
16
2.1
1
4.2
11
4.6
4
2.6
0
0
F
5
0.6
0
0
5
2.1
0
0
0
0
G
0
0
0
0
0
0
0
0
0
0
H
1
0.1
0
0
1
0.4
0
0
0
0
I
0
0
0
0
0
0
0
0
0
0
Total Records
779
100
24
3.1
239
30.6
151
19.4
365
Percent Harmful
2.8
4.2
7.1
2.6
0
Table 2.3 Example of Medication Error Sentinel Event in PreOp
Holding Area
Generic Name
Succinylcholine
sustaining interventions (Category H). The comparative findings of the Error
Category Index appear in Technical Appendix 2.
Patient in pre-op holding area awaiting surgery
for carpal tunnel repair. The pre-op holding nurse
started the patient’s IV line concluded the patient
examination and interview. The anesthesia
provider then saw patient and began providing preoperative medications. The anesthesia
provider intended to administer midazolam, famotidine, metoclopramide, and ondansetron, but
inadvertently swapped syringes and administered
succinylcholine instead. This error resulted in
immediate respiratory paralysis to the patient.
The patient was emergently transported to the
OR for intubation and general anesthesia. The
surgery proceeded as scheduled. Patient awoke
after surgery with no obvious deficits.
Medication Use Process
The increasing complexity of care in the Preop holding area has exacerbated
the opportunity for errors in the medication use process as the process is quite
different in the Preop holding area than in other areas of the hospital. A lack
of patient-specific written orders, orders that are often executed without the
purview of pharmacy supervision, contributes to the opportunities for errors
in the medication use process. When hospital nursing staff work in this area
medication orders should be written and pharmacy staff should review the
orders. Documentation of the medications administered by the nursing staff
must be done on the appropriate clinical form. In some institutions such documentation may appear on perioperative records rather than formal medication
Table 2-4. Node Associated with Preoperative Holding Area Records All Records
Node
Pediatric
Adult
Geriatric
Age not Provided*
n
%
n
%
n
%
n
%
n
%
Administering
352
57.5
19
79.2
183
77.6
112
74.2
38
19.2
Dispensing
44
7.2
1
4.2
16
6.7
9
6
18
9.1
Monitoring
9
1.5
0
0
5
2.1
2
1.3
2
1
Prescribing
73
11.9
1
4.2
18
7.5
12
7.9
42
21.2
Transcribing/
Documenting
134
21.9
3
12.5
17
7.1
16
10.5
98
49.5
Total
612
24
239
151
198
Node is not applicable to Category A records
When anesthesia providers work in this area, at times there are no written
orders, rather, the provider assesses the patient, selects the medication (from an
anesthesia cart or anesthesia kit), administers the medication, documents the
administration, and monitors for the effect.
As more and more activity ensues in the Preop holding area, the less likely the
staff will be able to maintain adequate monitoring of levels of consciousness,
respirations, anxiety, or other causes of concern to the patient. After some preoperative medications are administered, patients need increased observation for
adequate cardiac and/or respiratory effects, while other drugs may need to be
monitored for allergic reactions. Given the increase in care in this area, facilities must ensure appropriate monitoring equipment and rescue equipment is
readily available.
Findings
Based on actual medication errors (Categories B–I; n = 612), slightly more than
half of all errors originated in the Administering Node (Table 2-4), a finding
that increases to nearly three-quarters with each of the populations. The second leading Node for all populations was the Transcribing/Documenting. The
comparative findings appear in Technical Appendix 3.
From the information retrieved from MEDMARX, the greatest risk is that a
preop medication error will originate in the Administering phase of the medication use process.
Types of Medication Errors
The Type of Error field is a multi-select field that reporters use to characterize or describe the kinds of medication error, regardless of cause. Each type
of error could affect patients differently. For example, omission errors may
result in delayed procedures and lead to a disruption of the surgery schedule.
Omitting pre-procedural antimicrobial products has been linked to surgical site
infections,4 as antimicrobial prophylaxis initiated prior to the procedure reduces the burden on intra-operative contamination especially when administered
section 2 << 45
section 2
administration records used in other locations of the facility. Also, pharmacy
staff should be intricately involved in reviewing and approving the medications
that are stocked in the preop area as well as reviewing any non-urgent medication needed for care of a particular patient.
up to 60 minutes before surgical incision. The omission of drugs such as benzodiazepines may affect anesthesia induction. Incorrect amounts of drugs may
result in sub-therapeutic levels or an excessive dose may have toxic effects. As
the clinical nature changes in the Preop environment with more invasive lines
being placed, the chance for wrong route errors exponentially increases.
Findings
The vast majority of errors in the Preop holding area involved a limited number of Type of Error selections, as was seen in the Outpatient Surgery data.
There were 804 Type of Error selections in 764 records, indicative of records
containing more than one selection. Four selections, Wrong time, Omission
error, Prescribing error, and Unauthorized/wrong drug comprised nearly
Table 2-5. Types of Errors Associated with Preoperative Holding Area
All Records
section 2
Type of Error
Pediatric
Adult
Geriatric
Age not Provided*
n
%
n
%
n
%
n
%
n
%
Wrong time
288
37.7
4
16.7
36
15.1
22
15
226
63.8
Omission error
227
29.7
12
50
119
49.8
68
46.3
28
7.9
Prescribing error
80
10.5
1
4.2
17
7.1
9
6.1
53
15
Unauthorized/
wrong drug
80
10.5
0
0
31
13
26
17.7
23
6.5
Improper dose/
quantity
53
6.9
3
12.5
22
9.2
16
10.9
12
3.4
Drug prepared
incorrectly
18
2.4
2
8.3
6
2.5
3
2
7
2
Extra dose
16
2.1
0
0
7
2.9
4
2.7
5
1.4
15
2
1
4.2
8
3.3
5
3.4
1
0.3
Wrong patient
12
1.6
1
4.2
3
1.3
2
1.4
6
1.7
Wrong dosage form
4
0.5
0
0
0
0
1
0.7
3
0.8
Wrong route
9
1.2
0
0
6
2.5
1
0.7
2
0.6
1
0.1
0
0
0
0
0
0
1
0.3
Mislabeling†
1
0.1
0
0
0
0
0
0
1
0.3
804
24
255
157
368
Number of Records
764
24
239
147
354
Case Vignettes Group 4: Leading Types of Errors from Preoperative Holding Area Records
section 2
section 2 << 47
90% of the overall records (Table 2-5). As a percentage, the selection Wrong
time was associated with nearly 40% of all selections. Two other selections,
Improper dose/quantity and Drug prepared incorrectly combined for 9.3% of
the Preop records.
For the pediatric population, the selection most frequently cited was Omission
error (50%), followed by Wrong time (16.7%) and Improper dose/quantity
(12.5%). Omission errors were also the most common type of error in the adult
and geriatric population. There were no Wrong route or Wrong dosage form
reported errors in the pediatric population. The comparative findings appear
in Technical Appendix 4.
section 2
Medication errors rarely occur as the result of a single cause. Rather, they stem
from multiple causes and occur sporadically, making them more difficult to
anticipate. The consequences are often more serious when scheduled drugs are
involved. As the focus of clinical care evolves in Preop holding, so must the
processes that minimize the opportunity for errors to originate. Observing/
monitoring the patient prior to surgery is vital in this area, especially after the
administration of medications including intravenous fluids and peripheral
nerve blocks.
Findings
Of the 779 Preop medication error records, 771 identified at least one cause
of error, and many identified multiple causes as evidenced by the 1,944 total
number of error selections. The most often selected cause of error overall was
Performance deficit (Table 2-6). This was also true for pediatric errors (present in nearly two-thirds of the selections), as well as the adult and geriatric
patients (present in slightly more than half of the selections). The second most
often reported selection was Procedure/protocol not followed in the medication
errors overall and in both the adult and geriatric data, but not in the pediatric
data. Documentation was involved in 35.3% of the overall selections. These
three selections were overwhelmingly present in the overall data sample and
were often associated within the same record.
The pediatric data indicates that Performance deficit, Communication, and
Transcription inaccurate/omitted were the three most commonly identified
selections. These selections were also often associated with the same records.
The geriatric records identified Performance deficit, Procedure/protocol not
followed, and Communication as the three leading selections, again often being
selected as causes of error within the same record. The comparative findings
appear in Technical Appendix 5.
Factors contributing to medication errors are situational, environmental, and/
or organizational influences that influence the occurrence of the medication
errors. Contributing factors may not be entirely understood by staff and, therefore are often under-reported. Situational factors, such as Distractions and
Patient transfer may be indicative of the nature of care provided in the Preop
holding area – the interruptions and patient movement associated with high
turnover of patient volume also contributes to errors in this area.
The preoperative holding area is affected by the surgery schedule. The more
patients scheduled on a particular day, the greater chance of distractions and
increased patient transfer from outpatient/ambulatory care, nursing units, and
surgery rooms, etc. The continuous movement of patients through this area
can lead to omission of drugs, less time for observation, and workload stress.
Teamwork in this area important area can improve the workload.
Findings
Slightly more than two-thirds (61.3%) the actual errors (Category B–I; n = 612)
were associated with at least one contributing factor selection, though many
(n = 200) records indicated the selection None (Table 2-7). The selection,
Distractions, was present in varying percentages in records overall (21.3%),
pediatric (30%), adult (28.1%), and geriatric (26%) records. Two other contributing factor selections, Patient transfer (7.5%) and Cross coverage (6.7%) were
included in the four leading selections overall.
In the pediatric data set, Workload increase, Patient transfer, and Staff, inexperienced accounted for the remainder of the selections. The adult and geriatric
Table 2-6. Leading Causes of Error in Preoperative Holding Area
Pediatric
Adult
Geriatric
Age not
Provided*
n
%
n
%
n
%
n
%
n
%
Performance deficit
499
64.7
16
66.7
139
58.9
79
53
265
73.2
Procedure/protocol
not followed
372
48.2
4
16.7
68
28.8
55
36.9
245
67.7
Documentation
272
35.3
2
8.3
21
8.9
18
12.1
231
63.8
Computer software
220
28.5
0
0
3
1.3
0
0
217
59.9
Communication
136
17.6
7
29.2
56
23.7
48
32.2
25
6.9
Contraindicated,
drug allergy
45
5.8
1
4.2
13
5.5
9
6
22
6.1
Transcription inaccurate/
omitted
39
5.1
3
12.5
13
5.5
12
8.1
11
3
Cause of Error
Drug distribution system
27
3.5
1
4.2
10
4.2
7
4.7
9
2.5
Preprinted medication
order form
29
3.8
1
4.2
10
4.2
6
4
12
3.3
Knowledge deficit
42
5.4
1
4.2
18
7.6
14
9.4
9
2.5
System safeguard(s)
25
3.2
1
4.2
10
4.2
9
6
5
1.4
population had similar findings compared to the overall Preop records. The
comparative findings appear in Technical Appendix 6.
Actions Taken following a Medication Error
Actions taken as a direct result of an error are measures of how an organization
responds to errors. The ideal organizational culture encourages staff members
and managers to work together, communicate among disciplines to transform
the safety climate, and design and implement cultural changes in the work
place. The ideal patient safety culture encourages open reporting of errors in
the absence of punitive action, learning how to provide a safer environment
by reviewing errors and making corrections, and taking appropriate actions to
prevent future errors.
Findings
section 2 << 49
section 2
All Records
section 2
Case Vignettes Group 5: Leading Causes of Errors from Preoperative Holding Area Records
Case Vignettes Group 5: Leading Causes of Errors from Preoperative Holding Area Records CONTINUED
section 2
section 2 << 51
Table 2-7. Contributing Factors Associated with Preoperative Holding Area Records
All Records
section 2
Contributing Factor
Pediatric
Adult
Geriatric
Age not Provided*
n
%
n
%
n
%
n
%
n
%
None
199
53.1
4
40
51
37.8
37
38.5
107
79.9
Distractions
80
21.3
3
30
38
28.1
25
26
14
10.4
Patient transfer†
28
7.5
1
10
14
10.4
10
10.4
3
2.2
Cross coverage
25
6.7
0
0
13
9.6
10
10.4
2
1.5
Workload increase
24
6.4
2
20
12
8.9
9
9.4
1
0.7
22
5.9
1
10
15
11.1
4
4.2
2
1.5
No access to patient
information
6
1.6
0
0
3
2.2
2
2.1
1
0.7
Shift change
6
1.6
0
0
4
3
2
2.1
0
0
6
1.6
0
0
6
4.4
0
0
0
0
Emergency situation
5
1.3
0
0
1
0.7
1
1
3
2.2
No 24-hour pharmacy
4
1.1
0
0
1
0.7
1
1
2
1.5
Imprint, identification failure†
2
0.5
0
0
1
0.7
0
0
1
0.7
Staff, floating
2
0.5
0
0
1
0.7
0
0
1
0.7
Code situation
1
0.3
0
0
1
0.7
0
0
0
0
Computer System/
Network down
1
0.3
0
0
1
0.7
0
0
0
0
Patient names similar/same†
1
0.3
0
0
0
0
1
1
0
0
1
0.3
1
10
0
0
0
0
0
0
1
0.3
0
0
0
0
0
0
1
0.7
414
12
162
102
138
Most of the actions taken in this data set suggest opportunities to transform the
culture and implement sustainable changes in practice. Approximately 70% (n
= 548) of the Preop medication error records were associated with 749 selections
from the actions taken pick list (Table 2-8). The four leading selections, Informed
staff who made the initial error (67.7%), Education/training provided (19.5%),
Informed patient’s physician (18.2%), and Communication process enhanced
(10.2%) were present in 634 selections which represents about 85% of all selec-
tions. One third of the records contained multiple selections. For the pediatric
data, only five of the possible 13 selections were present; whereas, in the adult
data and geriatric, 10 of the possible 13 selections were evident. The comparative
findings appear in Technical Appendix 7.
Products Implicated in Medication Errors
Table 2-8. Actions Taken as a Direct Result of the Error for Preoperative Holding Area Records
Pediatric
Adult
Geriatric
Age not
Provided*
n
%
n
%
n
%
n
%
n
%
Informed staff who
made the initial error
371
67.7
5
62.5
91
61.9
48
60
227
72.5
Education/Training
provided
107
19.5
3
37.5
35
23.8
28
35
41
13.1
Informed patient’s
physician
100
18.2
2
25
44
29.9
18
22.5
36
11.5
Communication
process enhanced
56
10.2
2
25
28
19
11
13.8
15
4.8
Informed staff who was
also involved in error
51
9.3
3
37.5
23
15.6
15
18.8
10
3.2
None
25
4.6
0
0
6
4.1
5
6.3
14
4.5
of medication error
20
3.6
0
0
13
8.8
3
3.8
4
1.3
7
1.3
0
0
3
2
1
1.3
3
1
5
0.9
0
0
1
0.7
3
3.8
1
0.3
Policy/Procedure
instituted
4
0.7
0
0
3
2
1
1.3
0
0
Staffing practice/
policy modified
3
0.5
0
0
3
2
0
0
0
0
Action Taken
749
15
250
133
351
section 2 << 53
section 2
All Records
section 2
There is a breadth of products used in the Preop holding area, including antimicrobial agents, anxiolytics and sedatives, local anesthetics, and intravenous
fluids. As institutions further develop strategies to comply with the Joint
Commission’s National Patient Safety Goal of improving the use of all medications, the multi-disciplinary perioperative team must anticipate the impact of
the most commonly used products associated with preoperative care, including
high volume of certain classes of medications, such as antimicrobial agents and
the possible resultant medication errors. The omission of antimicrobial products prior to surgery can place the patient in a compromised position and infection becomes a major threat,5 especially for the pediatric and geriatric patient
who may already be in a compromised state. The teams must not overlook
“high-alert” products (i.e., meperidine, heparin, insulin, or succinylcholine)
and the potential for serious injury when using these products as they have
historically been implicated in serious medication errors. Products with narrow
therapeutic ranges require close physiological monitoring and should never
be used without precautions and specific monitoring in place as well as having
appropriate rescue equipment nearby in the event of an accidental overdose.
High-alert drugs require astute handing due to the potential life-threatening
events associated with their misuse. Despite this recognition, the propensity for
error remains and, therefore, the practitioners handling these products must
recognize the potentially serious outcomes and abide by proven safety practices
(e.g., independent double-checks).
Findings
Between March 14, 2003, and August 31, 2005, 288 records (out of 426) contained at least one product selection (Table 2-9) and some records contained
more than one. The five leading products from this data set were all antimicrobial agents for parenteral administration. There were 30 products reported,
half of which were antimicrobial agents.
instance of harmful products in the pediatric data set, 17 in the adult population, and three harmful medication errors involving the geriatric population.
When examining the products by the leading types of errors (Table 2-11), the
antimicrobial agents remain as the leading product selection.
Error Result on Level of Patient Care
Delay in treatments, supplementing drug therapy, and increasing patient
observation and monitoring result in increased resource expenditures for the
healthcare facility, as well as an increased workload for the staff in the preop
holding area. These expenditures contribute to the rising overall healthcare
costs. MEDMARX collects information in order to be able to demonstrate that
medication errors consume valuable resources.
Findings
The Error Result on Level of Patient Care was applicable for errors that
reached the patient (Categories
C– I). The majority of records (between two-thirds and three-quarters) designated the selection None, indicating that no additional care was rendered
(Table 2-12). This finding is internally consistent with the error category index
which suggests that most preoperative medication errors did not result in
patient harm.
There were 19 selections consistent with the care following an harmful event
(e.g., airway established, additional lab, antidotes or antagonists).
For the pediatric data, the majority of products involved in error were also antimicrobial agents, present in 10 of the 16 selections and five of the 9 products.
In the geriatric data, 11 of the 22 products were antimicrobial agents.
While an infrequent occurrence (n = 51), Delay in diagnosis/treatment/surgery,
was the second most commonly reported selection and suggests that an interruption in the surgery schedule was the result of the error. Such an action has
ripple effects throughout the perioperative continuum on scheduling personnel
and other resources.
In terms of harmful medication errors, there were 12 selections from 11
records. Only meperidine was reported in multiple records, compared to
the other products that were reported only once (Table 2-10). There was one
Summary of Preoperative Holding Area Medication Errors
Table 2-9. Most Commonly Reported Products Involved in Overall (Categories A–I) Preoperative Holding Area Medication Errors
All records
Products-Generic Name
Pediatric
Adult
Geriatric
Products-
Products-
n
%
%
Generic Name
n
%
Generic Name
n
%
Cefazolin
159
22
Cefazolin
9
33.3
Cefazolin
71
27.1
Cefazolin
28
14.9
Vancomycin
39
5.4
Ampicillin
3
11.1
Vancomycin
20
7.6
Vancomycin
13
6.9
Levofloxacin
22
3.1
Midazolam†
3
11.1
Levofloxacin
9
3.4
Cefuroxime
5
2.7
Midazolam†
19
2.6
Cefoxitin
2
7.4
Cefoxitin
8
3.1
Cyclopentolate
5
2.7
Cefoxitin
18
2.5
Acetaminophen
1
3.7
Dexamethasone
8
3.1
Famotidine
5
2.7
Heparin*†
16
2.2
5
2.7
Meperidine†
16
2.2
Morphine*†
16
2.2
Cefotetan
15
2.1
Famotidine
14
1.9
Ampicillin
12
1.7
Dexamethasone
12
1.7
Metoclopramide*
12
1.7
Gentamicin
10
1.4
Metronidazole
10
1.4
Ampicillin and
Sulbactam
9
1.3
Enoxaparin
9
1.3
Ceftriaxone
7
1.0
Cefuroxime
7
1.0
Fentanyl*†
7
Cyclopentolate
Ampicillin and
Sulbactam
1
Hydrocodone
and Acetaminophen
1
Penicillin V Potassium
1
Sodium Chloride
0.9%
1
3.7
3.7
Heparin*
8
3.1
Levofloxacin
Meperidine
8
3.1
Ampicillin
4
2.1
Famotidine
7
2.7
Cefoxitin
4
2.1
Midazolam
7
2.7
Heparin*†
4
2.1
2.1
Morphine*
7
2.7
Metoclopramide* 4
Cefotetan
6
2.3
Midazolam†
4
2.1
Oxymetazoline
6
2.3
Gentamicin
3
1.6
Ampicillin and
Sulbactam
5
1.9
Ceftriaxone
3
1.6
Clindamycin*
3
1.6
Enoxaparin
5
1.9
Enoxaparin
3
1.6
Gentamicin
5
1.9
3
1.6
Metoclopramide* 5
1.9
Lactated
Ringer’s
Phenylephrine*†
3
1.6
Piperacillin and
Tazobactam
3
1.6
Potassium Chloride*
3
1.6
1.0
6
0.8
Ceftazidime
2
1.1
Gatifloxacin
6
0.8
Fentanyl*†
2
1.1
Piperacillin and
Tazobactam
4
0.6
Data based on 150 records with
188 selections and 78 unique
products
Data based on 631 records with
719 selections and 139 unique
products
3.7
3.7
* Includes all dosage forms and formulations,
†Designates high-alert medication
section 2 << 55
section 2
n
Table 2-10. Harmful Medication Errors in Preoperative Holding Area (All Records, Pediatric, Adult, and Geriatric)
section 2
All records
Pediatric
Adult
Geriatric
Products-
Products-
n
%
%
6
33.3
Glycopyrrolate
1
33.3
1
5.6
Insulin*†
1
33.3
1
33.3
n
%
Generic Name
n
%
Generic Name
n
Meperidine†
6
37.5
Cefazolin
1
100
Meperidine†
Cefazolin
2
12.5
1
6.3
Data based on 1 records with 1
selections and 1 unique products
Cefazolin
Combined Electrolyte Solutions
Glycopyrrolate
1
Insulin*†
Combined Electrolyte Solutions
1
5.6
Sodium Chloride
0.9%
6.3
Glycopyrrolate
1
5.6
1
6.3
Insulin*†
1
5.6
Levofloxacin
1
6.3
Levofloxacin
1
5.6
Potassium Chloride*†
1
6.3
Potassium Chloride*†
1
5.6
Povidone Iodine
1
6.3
Povidone Iodine
1
5.6
Sodium Chloride
0.9%
1
6.3
Sodium Chloride
0.9%
1
5.6
Succinylcholine†
1
6.3
Succinylcholine†
1
5.6
† Designates high-alert medication
Table 2-11. Drill down by Leading Type of Error and Leading Products
Product
n
Wrong time
Cefazolin
21
Codeine sulfate
20
Aspirin
19
Penicillin V Potassium
15
Vancomycin
8
Cefazolin
77
Vancomycin
15
Levofloxacin
10
Midazolam*
10
Gentamicin
19
Omission error
Prescribing error
section 2
Type of Error
Cefazolin
Vancomycin
Levofloxacin
Midazolam*
Gentamicin
section 2 << 57
Preoperative holding areas have expanded the scope of perioperative care and
the majority of elective surgical patients can anticipate spending some time in
this clinical area. Medication errors occur in the preoperative holding area and
pose significant patient safety risks. This Report identifies recurring problems
originating in the preoperative holding area and USP suggests the following:
•
Confirming the processes for correct patient identification and correct
surgical site, especially if patient has been premedicated before coming to the
preoperative holding area;
section 2
•
Eliminating the potential for accidental administration of neuromuscular blocking agents in the Preop holding area;
•
Developing or utilizing sufficient documentation that tracks patients
through the continuum of care, and addresses the issues of “hand-offs” and lost
information;
•
Ensuring that sufficient staff members are available to administer preprocedural/preoperative antimicrobial agents in a timely and thorough fashion,
including the validation that the “piggy-back” was properly activated;
•
Expanding the opportunities for surgical team communication and
collaboration to address issues of patient readiness as they relate to scheduling;
•
Establishing documentation standards to ensure that preoperative
drugs have been given, IV sites are patent and the correct IV infusion is present, allergies are noted, and the patient’s condition is documented prior to
releasing the patient to the surgical suite;
•
Expanding the use of satellite pharmacy support such that medications are readily available and prepared within the area where the medications
are being administered;
•
Research or other investigations are needed to determine why policies and procedures are not being followed (given the high number of errors
associated with this cause). Such activity should determine if the policies are
Table 2-12. Level of Care Rendered as a Result of the Error
All Records
Pediatric
Adult
Geriatric
Age not
Provided*
Level of
Care selection
n
%
n
%
n
%
n
%
n
%
None
192
61
12
80
104
61.9
69
58.5
7
50
Delay in
diagnosis/
treatment/
surgery
51
16.2
0
0
26
15.5
23
19.5
2
14.3
Drug therapy initiated/
changed
49
15.6
3
20
24
14.3
19
61.1
3
21.4
incomplete, inaccurate, or missing as well as determining that staff are aware of
the policies and able to appropriately comply;
•
Healthcare should further investigate and implement concepts of
teamwork and train staff to accommodate workload demands through cooperation and adequate planning.
1.
Dunn D. Responsibility of the preoperative holding area nurse. AORN
Journal. 1997;66(5):820-844.
2.
Sullivan EE. Preoperatie holding areas. Journal of PeriAnesthesia
Nursing. 2000;15(5):353-354.
3.
McGraw T, Kendrick A. Oral midazolam premedication and postoperative behaviour in children. Pediatric Anesthesia. 1998;8:117-121.
section 2
4.
Mangram AJ, Horna TC, Pearson ML, Silver LC, Jarvis WR, The
Hospital Infection Control Practices Advisory Committee. Guideline for
prevention of surgical site infection, 1999. Infection Control and Hospital
Epidemiology. 1999;20:247-278.
5.
Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an
advisory statement from the National Surgical Infection Prevention Project.
Am J Surg. Apr 2005;189(4):395-404.
section 2 << 59
section 2
Section 3
Medication Errors Originating in the Operating Room (OR)
Section 3: Medication Errors Originating in the Operating Room (OR)
Action Taken Following an Error__________________________________ 24
Background.......................................................................................................3
Findings...........................................................................................................25
Table 3-1. Distribution of Operating Room Records by Error Category Index.3
Table 3-8. Actions Taken following an Operating Room Medication Error, by
Population.......................................................................................................26
Table 3-2. Error Category Index of Operating Room Medication Errors by
Population.........................................................................................................6
Table 3-3. Examples of Medication Error Sentinel Events in the Operating
Room.................................................................................................................7
Medication Use Process in the Operating Room_______________________ 9
Findings...........................................................................................................10
Findings...........................................................................................................27
Table 3-9. Most Commonly Reported Products Involved in Operating Room
Medication Errors, Categories A–I, by Population..........................................29
Table 3-10. Most Commonly Reported Products Involved in Harmful
(Categories E–I) Operating Room Errors, by Population................................31
Table 3-11. Drill down by Leading Type of Error and Leading Products......32
Findings...........................................................................................................12
Level of Care Rendered Following an Error_ ________________________ 33
Table 3-5. Types of Operating Room Medication Error by Population..........13
Findings...........................................................................................................33
Cause of Error_ ________________________________________________ 16
Table 3-12. Level of Care Rendered following an Operating Room
Medication Error, by Population.....................................................................34
Findings...........................................................................................................16
Table 3-6. Leading Causes of Error in Operating Room Records.................17
Case Vignettes Group 7: Leading Causes of Errors from Operating Room
Records...........................................................................................................18
Summary of Operating Room Medication Errors:____________________ 35
References_ ___________________________________________________ 37
Contributing Factors____________________________________________ 21
Findings...........................................................................................................21
Table 3-7. Contributing Factors associated with Operating Room Medication
Errors...............................................................................................................23
section 3 << 61
section 3
Table 3-4. Node Associated with Operating Room Medication Error Records,
by Population..................................................................................................11
Products______________________________________________________ 27
Background
For nearly a century, most surgeries were performed on inpatients at university
or community hospitals. Ambulatory surgery only became the norm during
the cost-containment era of the 1980’s; and as recently as 2001, more than 60%
of all surgical procedures were performed on outpatients.1 Surgery is often a
high-volume service area for many institutions, and with recent advances in
technology, it has become even more complex. This growing complexity is
accompanied by increased opportunities for medication errors.
section 3
Findings
Between September 1, 1998, and August 31, 2005, 447 facilities reported medication errors originating in the Operating Room (OR). Collectively, these
facilities submitted 3,773 records with 7.2% (n = 273) being reported as harmful
(Tables 3-I and 3-2). The OR data set contains 12 sentinel events (Categories
G through I), including two events where the medication errors may have contributed to or resulted in a patient’s death (Category I). Twelve events would
be considered as sentinel events and examples are provided (Table 3-3).
There were 126 (3.3%) pediatric records of which 21 (16.7%) were harmful,
including one patient death. Adult patients accounted for 1,272 records with
11.3% being harmful. Finally, geriatric patients were identified in 689 (18.2%)
medication errors records and two events required life-sustaining interventions following the errors. As a percentage of errors, the pediatric population
had more events with temporary harm and affecting length of hospitalization
(Categories E and F).
Medication Use Process in the Operating Room
The medication use process (MUP) is a multi-disciplinary process with overlapping phases of activities.2 Each phase in the MUP has both structures and
processes associated with professional responsibilities that minimize the risk of
a medication error.
The MUP functions differently in the OR as compared to other areas within
an institution. In a traditional setting, the provider writes an order, followed
by transcription of the order for implementation. The pharmacist reviews the
order and releases the product for usage. The product is administered to the
patient and the staff monitors the patient for any untoward effects. The MUP
differs in the OR and can be divided by medications used by the surgeon (as
retrieved by a nurse) and medications administered by an anesthesia provider.
For medications used by the surgeon, verbal orders or standing orders from
preference cards are the norm. There is little transcription and most ORs do
not have the support of direct pharmacy participation in preparing medications
for use. The sterile field creates unique challenges, as medications often must
be transferred from the original container to the surgical field for intra-operative use. For medications used by anesthesia, the medications are selected and
obtained from the anesthesia cart, and then administered by the anesthesia provider. The anesthesia provider performs most steps in the MUP and serves as
his or her own check for appropriateness, correct medication, and correct timing of administration. This practice eliminates any opportunity for pharmacy
review.
Safe medication administration practices have been detailed by the Association
of periOperative Registered Nurses (AORN). The AORN Medication Tool Kit 3
strives for the development of safe medication practices in the perioperative setting by addressing staff assessment and education, and by providing additional
resources. First published in 2002, and revised in 2006, the AORN Guidance
Statement: Safe Medication Practices in Perioperative Practice Settings Across
the Lifespan, offers clinicians in any invasive setting information regarding safe
medication practices.
Table 3-1. Distribution of Operating Room Records by Error Category Index
section 3
section 3 << 63
Table 3-2. Error Category Index of Operating Room Medication Errors by Population
All Records
Error Category
Pediatric
Adult
Geriatric
Age not
Provided*
n
%
n
%
n
%
n
%
n
%
A
557
14.8
0
0
0
0
0
0
557
33
B
769
20.4
0
0
2
0.2
0
0
767
45.5
C
1709
45.3
79
62.7
891
70
479
69.5
260
15.4
D
465
12.3
26
20.6
236
18.6
141
20.5
62
3.7
E
220
5.8
14
11.1
115
9
56
8.1
35
2.1
F
41
1.1
6
4.8
21
1.7
11
1.6
3
0.2
G
1
0
0
0
1
0.1
0
0
0
0
H
9
0.2
0
0
6
0.5
2
0.3
1
0.1
2
0.1
1
0.8
0
0
0
0
1
0.1
I
Total Records
3,773
section 3
Percent Harmful
126
7.2
1,272
16.7
689
11.3
1,686
10
2.4
Patient information is collected for errors that reach the patient (Categories C through I)
The Joint Commission’s National Patient Safety Goals promote specific
improvements in patient safety by highlighting problem-prone areas and
describing evidence-based solutions. Clinical areas performing invasive procedures can comply with Goal 3, Improve the safety of using medications, by
standardizing the medication formulary and limiting the number of concentrations available for use. By labeling all medications on and off of the sterile field,
facilities comply with another component of Goal 3. This latest requirement is
consistent with the best practices identified by AORN.3
Other organizations that have made significant contributions to perioperative
safety include the Institute for Safe Medication Practices and the American
Society of Anesthesiologists. The American Society of Anesthesiologists has
more than 100 years of advancing the standards of medical practice related
to anesthesia and is recognized as a leader in a never ending quest of patient
safety.4
Findings
Medication errors were noted throughout the entire medication use process in the OR, with the majority (56.3%) of the errors originating in the
Administering Node (Table 3-4). Prescribing Node errors comprised the
second most commonly reported errors overall (20.1%). The Monitoring and
Transcribing/Documenting Nodes show the lowest percentage of reported
errors overall.
Administering errors were also present in each of the populations reviewed
and this node accounted for the majority of pediatric (69.4%), adult (68.4%),
and geriatric (68.7%) errors. Only slight variations rest within the pediatric
and geriatric data. Two Nodes (Administering and Prescribing) had a slightly
higher percentage of occurrences in the pediatric data compared to the adult
or geriatric data. The errors in this node may be readily visible, which might
Table 3-3. Examples of Medication Error Sentinel Events in the Operating Room
Generic Name
Bupivacaine
A patient was inadvertently administered intravenous bupivacaine, which resulted in a seizure and a cardiac dysrhythmia.
Cefazolin
Following the administration of cefazolin, a patient experienced an anaphylactic reaction. After the patient was stabilized, it was determined that the
patient’s old chart contained the allergy information and that this information was not in the current chart.
Cocaine
Epinephrine
An otherwise healthy adult male sustained a bicycle accident, resulting in a nasal fracture and multiple facial lacerations. In order to obtain hemostasis, the surgeon placed cocaine-soaked pledgets and intended to inject the area with lidocaine with epinephrine. However, rather than lidocaine
with epinephrine, the surgeon injected 4 mL of 1:1000 epinephrine. As a result of the medication error, the patient’s blood pressure rose excessively, which was treated with an intravenous anti-hypertensive agent. Despite several hours of aggressive measures to stabilize the patient’s condition,
the patient expired.
As a result of the error, the institution adopted new policies that restricted the dispensing of cocaine and the storage
and availability of multi-dose vials of epinephrine.
Surgeon gave verbal order to anesthesiologist to give intravenous digoxin and mis-spoke the dose. The surgeon meant to say 18 mcg (was thinking
of a different product) but said 180 mcg. The anesthesia provider did not pick up that the dose was excessive. As a result of the error, the infant
died of toxicity despite aggressive and appropriate resuscitation.
Epinephrine
An adult male was given epinephrine 1:1000 intra-articularly, which resulted in cardiac arrest. Following stabilization, the patient was admitted to
the intensive care unit.
Heparin
A first year resident was left unattended in the OR during a complicated facial plastic surgery case on a young adult female. The attending surgeon
ordered heparin 2,000 units and the resident misinterpreted the heparin’s concentration as 1,000 units/vial rather than 1,000 units/mL, packaged
in a 20 mL vial (20,000 units). The resident, unfamiliar with the medication and the label, gave 2 vials (a 20-fold overdose). The error was detected
7 hours later by a senior resident relieving the first year resident. As a result of the error, the patient had extensive bleeding and required multiple
blood product transfusions. The patient experienced post-operative complications including loss of facial soft tissue.
Potassium Chloride
A patient sustained a cardiac arrest after receiving the wrong dose of potassium chloride as a result of an intravenous pump malfunction. Following
stabilization, the patient was transferred to the intensive care unit.
Succinylcholine
While a patient was being prepared for surgery and anesthesia induction, the anesthesia provider administered a neuromuscular blocking agent.
However, the intravenous (IV) line had infiltrated, thus the medication was in the tissue surround the IV site. A new IV line was initiated and a
second dose of the neuromuscular blocking agent was given. The surgery was completed and the patient transported to the post anesthesia care
unit (PACU). While in PACU, the patient’s oxygen saturation level began to decrease and the patient was unable to breath. The patient had to be
intubated and transferred to an intensive care unit.
section 3 << 65
section 3
Digoxin
Table 3-4. Node Associated with Operating Room Medication Error Records, by Population
All Records
Pediatric
Adult
Geriatric
n
%
n
%
n
%
n
%
n
%
1,810
56.3
127
69.4
870
68.4
473
68.7
340
31.7
Prescribing
646
20.1
28
15.3
189
14.9
87
12.6
342
31.9
Dispensing
372
11.6
15
8.2
93
7.3
57
8.3
207
19.3
Transcribing/
Documenting
325
10.1
11
6
108
8.5
62
9
144
13.4
Monitoring
63
2
2
1.1
12
0.9
10
1.5
39
3.6
Node
Administering
Total Records
3,216
183
Age not Provided*
1,272
689
1,072
section 3
explain the high occurrences. Three Nodes (Transcribing, Dispensing, and
Monitoring) had a slightly higher percentage of occurrence in the geriatric data
compared to the pediatric data. The comparative findings appear in Technical
Appendix 3.
Type of Error
The Type of Error field is a multi-select field used by reporters to characterize
or describe the medication error, regardless of the cause(s). Pareto-type observations suggest that 80% of the problems stem from 20% of the conditions.5
By addressing the 20% which are causing 80% of the problems, measurable
improvements can be made and monitored for continuous progress.
Findings
In the Operating Room, there were 90.5% (n = 3,416) records that identified
at least one type of error. The total number of Type of Error selections from
the multi-select pick list were 3,601, indicating that in some records, more than
one selection was chosen. For all Operating Room records, the leading selections were Omission error, Unauthorized/wrong drug, Prescribing error, and
Improper dose/quantity (Table 3-5). Together, these four selections represent
74.9% of the error records. The majority of errors involved a limited number
of Type of Error selections, congruent with the Pareto principle.
There was some variation in the rank ordering of OR errors involving pediatric patients, adult patients, and geriatric patients compared to the errors
overall (Table 3-5). Approximately one-third (32.4%) of the pediatric records
contained errors involving an Improper dose/quantity, compared to 14.6% in
the adult population and 15.4% in the geriatric population. This finding was
double the percentage of overall selections (15.9%). Unauthorized/wrong drug
was the second most commonly reported selection in the pediatric data and
was in line the other populations. As a percentage of errors reported, Extra
dose errors involved the pediatric population more often than the geriatric
population or errors overall. Most of these errors resulted from breakdowns in
communication between providers following handoffs and failure to document
doses given. Another variation noted in the adult and geriatric populations
were Omission errors (27.3% and 29.7%, respectively), a finding nearly double
Table 3-5. Types of Operating Room Medication Error by Population
All Records
Pediatric
Adult
Geriatric
Age not Provided*
n
%
n
%
n
%
n
%
n
%
732
21.4
26
15
322
27.3
191
29.7
193
13.6
703
20.6
32
18.5
250
21.2
118
18.3
303
21.3
Prescribing error
581
17
16
9.2
158
13.4
78
12.1
329
23.2
543
15.9
56
32.4
172
14.6
99
15.4
216
15.2
249
7.3
11
6.4
75
6.4
58
9
105
7.4
Wrong time
208
6.1
14
8.1
82
7
39
6.1
73
5.1
Wrong administration
technique
121
3.5
9
5.2
49
4.2
25
3.9
38
2.7
Wrong patient
120
3.5
5
2.9
28
2.4
18
2.8
69
4.9
Extra dose
111
3.2
11
6.4
35
3
31
4.8
34
2.4
86
2.5
0
0
6
0.5
1
0.2
79
5.6
Wrong route
49
1.4
3
1.7
25
2.1
13
2
8
0.6
Expired product†
41
1.2
0
0
8
0.7
3
0.5
30
2.1
Wrong dosage form
33
1
1
0.6
12
1
3
0.5
17
1.2
Mislabeling †
24
0.7
1
0.6
10
0.8
1
0.2
12
0.8
3,601
185
1,232
678
1,506
Number of Records
3,416
173
1,179
644
1,420
section 3 << 67
section 3
Type of Error
Omission error
section 3
Case Vignettes Group 6: Types of Errors from Operating Room Records
section 3
section 3 << 69
the pediatric finding (15%). Pediatric errors disproportionately involved an
Improper dose/quantity or the wrong amount. This finding is not surprising
given the number of steps required (e.g., weight conversions, weight-based dosing, and manipulation of adult dosages) to get final doses needed for this age
group. Together, these findings suggest two areas for immediate improvement
efforts – addressing the final dose requirements for pediatrics and the omissions. The comparative findings appear in Technical Appendix 4.
such as the lower percentage of Contraindicated, drug allergy, in the pediatric
population may be due to the relatively small pediatric sample. The percentage
of Calculation errors was significantly greater in the pediatric population than
either the geriatric population or errors overall (the full comparative data is
contained in Technical Appendix 5).
Contributing Factors
section 3
Cause of Error
How do medication errors happen in the operating room? Normal accident
theory suggests that errors result from system failures.6 Leaders within the
operating room must learn to examine their clinical practice and the general
environment from a systems perspective. Such examination must include how
healthcare workers complete their duties through interaction with the system
from a human factors perspective. Systems-level areas that warrant scrutiny
include: 1) Assuring that existing policies and procedures are up-to-date and
congruent with current, evidence-based practice and workable, 2) improving
communication among the team members, 3) providing better allergy information to all team members, and 4) ensuring appropriate training and competency
in the utilization of technical equipment as well as complying with maintenance
and repair schedules.
Findings
The majority (95.3% or n = 3,596) of the records contained at least one Cause
of Error selection from the multi-select pick list. These records were associated with 6,466 Cause of Error selections, indicating that many of the records
contained more than one selection. The Causes of Errors associated with the
operating room suite were very similar across the perioperative environments
for the majority of Cause of Error selections indicating that homogeneity was
present. Three selections, Performance deficit, Procedure/protocol not followed, and Communication represent more than 85% of the total selections in
errors overall, 93.6% of the pediatric errors, and 95.7% of the geriatric errors.
There was little variation in the leading nine Causes of Error between errors
overall and the pediatric and geriatric errors (Table 3-6). Some of the variation,
Contributing Factors are situational, environmental, organizational, or a combination of, influences that may affect the occurrence of the medication errors.
Because of their influential nature, they differ from a Cause of Error. Based on
these findings, Contributing Factors appear to be under-reported or not entirely understood. Situational factors and environmental factors are time-limited
and it may be difficult to predict their occurrences. Organizational factors,
such as staffing policies, may result in latent conditions imposed in the healthcare system by others not directly involved in medication error events. Such
failures may be so common that they are woven into the fabrics of healthcare in
such a way that healthcare workers fail to recognize them or distinguish them
from normal duties.7
The perioperative environment faces other factors that should be of concern.
For example, the present workforce includes an aging population that will soon
be eligible for retirement. Many of the professional educational programs have
reduced clinical experiences for students in the perioperative area. Together,
these conditions will likely lead to a future staffing concern. Another current concern is the pace at which technology continues to change. Ensuring
staff competency in a rapidly changing environment must remain a priority to
address patient safety needs. The impact of new technology on workflow and
staff satisfaction must be integrated into the patient safety plan.8
Findings
list became mandatory in 2003. Slightly less than one third (30.6% or n = 857)
of the Operating Room records were associated with at least one selection. The
majority of all records selected captured either None or Distractions as contributing to the error (Table 3-7). The majority of the Contributing Factors selec-
Table 3-6. Leading Causes of Error in Operating Room Records
All Records
Pediatrics
Adults
Geriatrics
Age not Provided*
Cause of Error
n
%
n
%
n
%
n
%
n
%
Performance deficit
1,502
41.8
70
40.9
552
45.4
295
44.5
585
37.8
Procedure/protocol
not followed
979
27.2
48
28.1
318
26.2
194
29.3
419
27.1
Communication
650
18.1
42
24.6
281
23.1
145
21.9
182
11.8
Documentation
484
13.5
20
11.7
143
11.8
74
11.2
247
16
Contraindicated,
drug allergy
337
9.4
7
4.1
114
9.4
55
8.3
161
10.4
Knowledge deficit
331
9.2
20
11.7
126
10.4
67
10.1
118
7.6
Dispensing device involved
176
4.9
2
1.2
31
2.5
21
3.2
122
7.9
Transcription inaccurate/omitted
155
4.3
2
1.2
37
3
20
3
96
6.2
148
4.1
6
3.5
61
5
37
5.6
44
2.8
129
3.6
6
3.5
47
3.9
30
4.5
46
3
Packaging/container design
126
3.5
5
2.9
34
2.8
19
2.9
68
4.4
Verbal order
102
2.8
10
5.8
41
3.4
17
2.6
34
2.2
Similar packaging/labeling
87
2.4
7
4.1
32
2.6
18
2.7
30
1.9
Written order
104
2.9
3
1.8
29
2.4
16
2.4
56
3.6
Preprinted medication
order form
80
2.2
0
0
19
1.6
10
1.5
51
3.3
Monitoring inadequate/lacking
93
2.6
5
2.9
34
2.8
23
3.5
31
2
Labeling (your facility’s)
74
2.1
5
2.9
25
2.1
15
2.3
29
1.9
Computer entry
55
1.5
2
1.2
10
0.8
11
1.7
32
2.1
Calculation error
71
2
17
9.9
29
2.4
10
1.5
15
1
Pump, improper use
61
1.7
11
6.4
29
2.4
11
1.7
10
0.6
Percentages based on
Number of Records
3,596
171
1,216
663
1,546
section 3 << 71
section 3
System safeguard(s)
section 3
Case Vignettes Group 7: Leading Causes of Errors from Operating Room Records
Case Vignettes Group 7: Leading Causes of Errors from Operating Room Records
section 3
section 3 << 73
tions were associated with fewer than 10% of the records, a finding that carried
through in the pediatric population and the geriatric population. The comparative findings appear in Technical Appendix 6.
Of the 18 possible contributing factors pick list selections, six serve as proxy
measures for the impact of staffing patterns on error events: (a) Staff, inexperienced; (b) Staff, floating; (c) Staff, agency/temporary; (d) Staffing insufficient;
(e) Staffing, alternative hours; and (f) Cross coverage. Staffing issues were cited
296 times in 8.7% (n = 279) of the OR records where an actual error occurred
(Categories B-I). The recent nursing shortage has forced institutions to increase
utilization of temporary/agency or float staff, which in turn can result in having
staff less familiar with the institution’s policies and procedures.
section 3
Workload increases can be too dynamic and not managed by scheduling alone.
Rather, innovative scheduling and/or mobilization of available resources may also
need to occur in order to deal with unexpected emergency cases.
Interventions directed at practitioners are least likely to result in sustainable
changes. However, these actions are also easier to implement and range from a
simple exchange between practitioner to formal training or education.
Findings
Slightly less than half (n = 1,319 or 47.2%) of the records documented an action
taken as a direct result of the medication error. The selection most often reported was Informed staff who made the initial error followed by Communication
process enhanced (Table 3-8). Slightly more than 10% of the records indicated
that no additional action occurred.
The OR responses, compared to other patient care settings where MEDMARX
have been analyzed,10 appear favorable from the context of actions taken
as a result of medication errors. Four selections are especially noteworthy
(Communication process enhanced, Policy/procedure changed, Staffing practice/
policy modified, and Environment modified) given they convey that an active
nature of attempting to reduce further errors.
Action Taken Following an Error
Actions taken after an error can be directed to either the systems level or the staff
level and serve as measures for how individuals and institutions respond following an error. These actions are directly linked to the culture of the organization.
The ideal culture is one of safety that seeks to learn from mistakes in order to
avoid repeating the mistake at a future time. The interventions themselves can be
aimed at organizational levels changes or individual level changes. Organizational
changes have included the Joint Commission’s expansion of the third National
Patient Safety goal to requiring labeling of all medications on the sterile field.
The Joint Commission developed this goal in response to several serious events
involving unlabeled solutions on the field. Most hospitals are adapting their
internal policies to address this new standard. Wrong site surgery errors being
reported in the media may have been a wake up call to all OR staff to increase
communication among members of the operating room team. As a result of such
errors, the Universal Protocol for Preventing Wrong Site, Wrong Procedure,
Wrong Person SurgeryTM was created and adopted as a standard of care.9
These types of interventions are aimed at transforming the system for sustainable
change.
Products
Contemporary surgery would not be possible without the adjunctive use of pharmacological agents. Drug products are used to induce anesthesia, reduce the
opportunity for surgical wound infections11, as adjuncts for hemostasis, for pain
reduction and for irrigations. Antimicrobials are often given for the prevention
of surgical-wound infections and it is generally recognized that the risk of infection decreases when the agents are given less than one hour before incision.12
Agents are continued for up to 24 hours post operative to ensure appropriate
prophylaxis and reduce the opportunity for drug-resistant pathogens.
Findings
These data indicate that there are a wide variety of products involved in the
operating room, given that 343 different products were implicated in errors.
The majority of products involved in errors were antimicrobial agents or narcotics. Most antimicrobial agents are administered via the intravenous piggy-back
method (IVPB).
Table 3-7. Contributing Factors associated with Operating Room Medication Errors
All Records
Pediatric
Adult
Geriatric
Age not
Provided*
Contributing
Factor
n
%
n
%
n
%
n
%
n
%
None
488
39.8
24
35.3
204
38.1
105
38.2
155
44.4
Distractions
320
26.1
20
29.4
153
28.6
63
22.9
84
24.1
165
13.4
12
17.6
65
12.1
33
12
55
15.8
Workload
increase
88
7.2
0
0
45
8.4
21
7.6
22
6.3
Cross coverage
75
6.1
2
2.9
35
6.5
20
7.3
18
5.2
section 3
section 3 << 75
section 3
Case Vignette Group 8: Contributing Factors with Post Anesthesia Care Unit Records
Table 3-8. Actions Taken following an Operating Room Medication Error, by Population
All Records
Pediatric
Adult
Geriatric
Age not
Provided*
Action
Taken
n
%
n
%
n
%
n
%
n
%
Informed
staff who
made the
initial error
940
51.2
23
51.1
348
50.8
217
55.4
352
49.4
Informed
staff who
was also
involved in
error
361
19.7
7
15.6
145
21.2
93
23.7
116
16.3
Nearly 88% of the Operating Room records (n = 3,298) identified at least one
product involved in an error and many records contained more than one product, as evidenced by the 3,703 product selections (Table 3-9). The most commonly identified product involved in errors in this area was cefazolin, which
is the most commonly used antibiotic for surgical prophylaxis, and thus is a
‘high-volume’ agent. It was reported nearly twice as often as fentanyl, the second leading product. Other commonly reported products included morphine,
midazolam, and heparin. Four of the five leading products are considered
“high alert” medications.
For the 171 pediatric records, 59 unique products were reported, again with
cefazolin being the most commonly reported product. This was followed by
acetaminophen. Three high alert medications (midazolam, fentanyl, and morphine) rounded out the leading five selections in the pediatric population.
Products were examined by leading types of errors (Table 3-11). The three
most common types of errors (Unauthorized/wrong drug, Omission error,
and Prescribing error) were associated with antimicrobial agents as the leading
product. Of interest was the other two leading types of errors (Improper dose/
quantity and Drug prepared incorrectly). The five leading products (fentanyl,
midazolam, heparin, morphine, and epinephrine) associated with Improper
dose quantity were all “high alert” medications as were four products associated
with Drug prepared incorrectly (lidocaine, heparin, midazolam, and phenylephrine).
section 3
For adult records (n = 1,191), there were 254 unique products identified in the
1,320 selections. Again, cefazolin was the leading product identified, followed
by morphine, heparin, vancomycin, and bupivacaine. Finally, for the 645 geriatric records, involving 729 selections and 149 unique products, three of the
leading five products were antimicrobial agents.
phenylephrine. Fentanyl was the most common product reported in harmful
pediatric errors. Insulin errors were reported in the geriatric population. Two
themes were present when reviewing error descriptions of the harmful events:
administering the wrong dose of the agent or omitting the dose altogether, such
as the cases involving cefazolin.
When reviewing error descriptions, several themes emerged, of which three,
were closely associated with intravenous piggy-backs (IVPBs). First, some
IVPBs were never activated (i.e., advantage or add-a-vial), meaning, only the IV
solution was infused, not the antimicrobial agent. Second, many of the IVPB
infusions were never connected to intravenous tubing, leaving the infusion to
spill onto the floor or patient bedding. A third theme was the rapid infusion of
some IVPB medications, particularly vancomycin, which led to adverse effects.
Addressing many of these problems associated with IVPBs will advance medication safety in the OR. Finally, it was noted that medications often require
additional manipulation just prior to transferring to the sterile field. Having
medications available in sterile, ready-to-use packaging would alleviate this
issue.
There were 96 products involved in all harmful errors (Table 3-10). Products
that were reported among the sample included neuromuscular blocking agents
(such as rocuronium or vecuronium), epinephrine, lidocaine, dopamine, and
section 3 << 77
section 3
Table 3-9. Most Commonly Reported Products Involved in Operating Room Medication Errors, Categories A–I, by Population
All Records
Products-Generic
Name
n
%
Cefazolin
571
15.4
Fentanyl*†
294
7.9
Morphine*†
193
5.2
Midazolam†
150
4.0
Heparin*†
143
3.9
Vancomycin
107
2.9
Bupivacaine
77
2.1
Meperidine†
72
1.9
Lidocaine*
70
1.9
Gentamicin
64
1.7
Epinephrine*† 62
1.7
Cefotetan
61
1.5
Ketorolac
56
1.5
Phenylephrine* 35
0.9
Cefoxitin34
0.9
Ampicillin
34
0.9
Clindamycin*
32
0.9
Insulin*†31
0.8
Data based on 3,298 records Involving 3,703 selections and 343 unique
products
Pediatric
Products-Generic
Name
n
%
Cefazolin
22
11.5
Acetaminophen 15
7.9
Midazolam†
10
5.2
Fentanyl*†
8
4.2
Morphine*†
8
4.2
Dopamine*†
6
3.1
Cefotetan
5
2.6
Vancomycin
5
2.6
Milrinone
5
2.6
Heparin*†
4
2.1
Ketorolac
4
2.1
Cefoxitin4
2.1
Baclofen4
2.1
Epinephrine*† 4
2.1
Clindamycin*
3
1.6
Rocuronium†
3
1.6
Bupivacaine 3
1.6
Alprostadil
2
1.0
Ampicillin
2
1.0
Cisatracurium 2
1.0
Data based on 171 records Involving 191 selections and 59 unique
products
† Denotes high-alert medication
Adult
Products-Generic
Name
n
%
Cefazolin
237
18.0
Morphine*†
64
4.8
Heparin*†
61
4.6
Vancomycin
39
3.0
Bupivacaine
35
2.7
Meperidine
32
2.4
Ketorolac
30
2.3
30
2.3
Lidocaine*
Midazolam
30
2.3
Fentanyl*†
27
2.0
Cefotetan
24
1.8
Gentamicin
23
1.7
Epinephrine*† 22
1.7
Cefoxitin19
1.4
Povidone Iodine 19
1.4
Ampicillin
16
1.2
Ampicillin and Sulbactam 16
1.2
Bupivacaine and Epinephrine
16
1.2
Clindamycin*
16
1.2
Levofloxacin
16
1.2
Data based on 1,191 records involving 1,320 selections and 254 unique
products
Geriatric
Products-Generic
Name
n
%
Cefazolin
123
16.9
Heparin*†
42
5.8
Vancomycin
33
4.5
Morphine*†
29
4
Gentamicin
21
2.9
Midazolam†
21
2.9
Fentanyl*†
18
2.5
Lidocaine*
14
1.9
Cefotetan
15
2.1
Bupivacaine
12
1.5
Epinephrine*† 13
1.8
Nitroglycerin*
11
1.5
Ciprofloxacin
8
1.1
Dexamethasone 8
1.1
Meperidine†
11
1.5
Ceftriaxone
7
1
Levofloxacin
6
0.8
Metronidazole 7
1
products
Table 3-10. Most Commonly Reported Products Involved in Harmful (Categories E–I) Operating Room Errors, by Population
Pediatric
Products-Generic
Name
n
%
Fentanyl*†
4
15.4
Baclofen3
11.5
Dopamine*†
2
7.7
Morphine*†
2
7.7
Acetaminophen and Codeine
1
3.8
Ampicillin
1
3.8
Cefotetan
1
3.8
Clindamycin Phosphate 1
3.8
Digoxin 1
3.8
Heparin*†
1
3.8
Hydrocortisone 1
3.8
Lactated Ringer’s Injection1
3.8
Milrinone
1
3.8
Rocuronium†
1
3.8
Sodium Chloride 1
3.8
Vecuronium†
1
3.8
Data based on25 records Involving
26 selections and 19 unique products
Adult
Products-Generic
Name
n
%
Cefazolin
14
10.8
Heparin*†
12
8.2
Midazolam†
10
7.7
Morphine*†
9
6.9
Epinephrine*† 7
5.4
Fentanyl*†
7
5.4
Bupivacaine
5
3.8
Lidocaine*†
4
3.0
Rocuronium
4
3.0
Vancomycin
4
3.0
4
3.0
Vecuronium†
Data based on 155 records involving 130 selections and 70 unique
products
Geriatric
Products-Generic
Name
n
%
Cefazolin
6
8.0
Heparin*†
5
6.7
Vancomycin
5
6.7
Fentanyl*†
4
5.3
Insulin*†4
5.3
Sufentanil
4
5.3
Bupivacaine
3
4.0
Lidocaine*†
3
4.0
Midazolam†
3
4.0
Morphine*†
3
4.0
Dopamine*†
2
2.7
Epinephrine*† 2
2.7
Nitroglycerin*† 2
2.7
Phenylephrine*† 2
2.7
Propofol†
2
2.7
Data based on 67 records involving
75 selections and 40 unique products
t
†Denotes high-alert medication
* Include all dosage forms and formulations
section 3 << 79
section 3
All Records
Products-Generic
Name
n
%
Cefazolin
25
9.1
Heparin*†
18
6.6
Fentanyl*†
16
5.8
Midazolam†
14
5.1
Morphine*†
14
5.1
Vancomycin
13
4.7
Epinephrine*† 11
4.0
Lidocaine*†
9
3.3
Bupivacaine
8
2.9
Insulin*†7
2.6
Rocuronium†
6
2.2
Sufentanil
6
2.2
Vecuronium†
6
2.2
Dopamine*†
5
1.8
Phenylephrine*† 5
1.8
Ketorolac
4
1.5
Propofol†
4
1.5
products
Table 3-11. Drill down by Leading Type of Error and Leading Products.
Type of Error
Product
n
Omission error
Cefazolin
Vancomycin
Gentamicin
Cefotetan
Heparin†*
246
24
23
20
20
section 3
Fentanyl†
Cefazolin
Morphine†*
Heparin†*
Level of Care Rendered Following an Error
The OR is a fast-paced area with little time for extra monitoring or observation
after a procedure or operation is nearing completion and the patient is ready for
transfer to the PACU. The Error Result on Level of Patient Care is applicable
for errors that reach the patient (Categories C– I). Such activities could slow the
processes in the OR and requires extra time and staff impacting the entire perioperative setting.
Findings
Medication errors in the operative setting are frequently associated with additional care to the patient,
When additional care was needed, it most often involved increasing patient monitoring through direct observation, or more closely checking vital signs, or initiating/changing the drug therapy. The majority of records (nearly 60%) included
the selection None, indicating that no additional care was rendered (Table 3-12).
This finding was also noted in the pediatric and geriatric records.
Table 3-12. Level of Care Rendered following an Operating Room Medication Error, by Population
Pediatric
Adult
Geriatric
Age not
Provided
Level of
Care
n
%
n
%
n
%
n
%
n
%
None
907
58.3
66
52.4
529
59.8
285
57.8
27
50.9
Observation
initiated/
increased
292
18.8
22
17.5
165
18.6
98
19.9
7
13.2
Drug
therapy
initiated/
changed
251
16.1
23
18.3
130
14.7
88
17.8
10
18.9
Vital signs
monitoring initiated/increased
141
9.1
16
12.7
77
8.7
47
9.5
1
1.9
section 3
All Records
section 3 << 81
Summary of Operating Room Medication Errors:
Medication errors occurring in the Operating Room are associated with increased
morbidity and mortality and this Report identifies recurring threats to safe medication use in the Operating Room. Priority areas that USP has identified for further improvement are:
•
Institutions and professional associations should call upon manufacturers to produce drug products in ready-to-use packaging with sterile, duplicate
labels to avoid errors with labelling. As soon as commercially available, hospitals
should obtain as many products in sterile ready-to-use packaging as possible;
section 3
•
A multidisciplinary team should periodically examine preference cards
(physician requirements for a particular procedure) to ensure appropriate use of
abbreviations or acronyms, ensure clarity of medications intended for the procedure, affirm instruments and equipment needed for the case. There should also
be evidence to the last date the card was reviewed. To the extent possible, facilities should adopt technology consistent with the benefits of CPOE.
•
To the extent possible, institutions should have dedicated satellite pharmacies and a sufficient number of appropriately stocked automated dispensing
devices to provide medications used in connection with the procedure.
•
Practitioners should have access to accurate patient information, standardized dose charts, and/or assistive technologies with proper medication calculations and formulations so no patient will be at risk of receiving the wrong dose
of drug.
•
Health care practitioners should strive for the establishment and maintenance of a culture of safety and open communication, which includes appropriate “briefing and debriefing”. Event reporting and documentation of system’s
level actions must be included in the culture of safety.
•
The “Time-Out” standard should be expanded to allow sufficient review
of the preference card, confirmation of the medication directions, confirmation
of patient allergies, and confirmation of pre-procedural antibiotics.
•
Practitioners should adhere to the practice of ‘repeat and verification’
during hand off between scrub personnel and surgeons.
•
Practitioners must examine policies and procedures for accuracy and
clarity. Institutions must examine why policies are not being followed, which
may include an assessment of the practitioner’s awareness of the policies.
•
Verbal communication between circulating nurse and scrub personnel
must be clear and both must confirm the drugs on the sterile field as well as the
labelling of the drugs on the field.
•
Labelling of all medications should be done to accommodate the needs
of the anesthesia provider as well as the sterile field. Labelling should be done
in accordance with generally accepted safety standards (product name, strength,
staff preparing, etc).
•
Original research is needed to investigate how electronic or computer
entry integrates with the electronic health record in this unique environment.
•
Leadership should have better understanding of the actions taken in
response to an error in order to determine which interventions are most likely to
result in sustained changes and reduce the burden of medication errors.
•
Confirming the processes for correct patient identification and correct
surgical site, especially if patient has been medicated. A parent and/or family
member should be present and serve as the proxy for verifying pediatric patient
identification and surgical procedure.
References
1.
National Center for Health Statistics. National Health Care Survey.
http://www.cdc.gov/nchs/data/factsheets/nhcs.pdf. Accessed October 3, 2005.
2.
3.
4.
American Society of Anesthesiologists. Patient Safety Corner. http://
www.asahq.org/safety.htm. Accessed September 20, 2006.
5.
AORN Medication Tool Kit. Denver; 2005.
Curry D. The Pareto Principle. Field Notes. 2001;10(3).
6.
Ruchlin HS, Dubbs NL, Callahan MA, Fosina MJ. The role of leadship
in installing a culture of safety: Lessons from the literature. Journal of Healthcare
Management. 2004;49(1):47-59.
8.
Stahl JE, Egan MT, Goldman JM, et al. Introducing new technology into
the operating room: measuring the impact on job performance and satisfaction.
Surgery. May 2005;137(5):518-526.
7.
9.
Joint Commission on Accreditation of Healthcare Organizations.
Universal protocol for preventing wrong site, wrong procedure, wrong person
surgery ™. Accessed September 1, 2005.
10.
section 3
section 3 << 83
section 3
Section 4
Medication Errors Originating in the Post Anesthesia Care Units
Section 4: Medication Errors Originating in the
Post Anesthesia Care Units_______________________________ 1
Background.......................................................................................................3
Table 4-7. Contributing Factors associated with Post Anesthesia Care Unit.23
Findings.............................................................................................................4
Case Vignette Group 11: Contributing Factors with Post Anesthesia Care
Unit Records....................................................................................................24
Table 4-1. Distribution of Post Anesthesia Care Unit Records by Error
Category Index..................................................................................................5
Findings...........................................................................................................22
Findings...........................................................................................................25
Table 4-2. Comparison of Post Anesthesia Care Unit Medication Errors by
Error Category Index and Population................................................................7
Table 4-8. Actions Taken as Reported in Post Anesthesia Care Unit Records,
By Populations................................................................................................26
Table 4-3. Examples of Sentinel Event Medication Errors in PACU...............8
Products Involved in Medication Errors____________________________ 27
Node of the Medication Use Process_ ______________________________ 11
Findings...........................................................................................................11
Table 4-9. Most Commonly Reported Products Involved in Overall
(Categories A–I) Post Anesthesia Care Unit Errors.........................................30
Background.....................................................................................................13
Table 4-10. Most Commonly Reported Products Involved in Harmful
(Categories E–I) Post Anesthesia Care Unit Errors.........................................32
Findings...........................................................................................................13
Error Result on Level of Patient Care:______________________________ 35
Table 4-5. Types of Errors Associated with Post Anesthesia Care Unit
Records...........................................................................................................15
Findings...........................................................................................................35
Summary of Post Anesthesia Care Unit Medication Errors............................37
Table 4-6. Leading Causes of Error in PACU Records, by Population..........19
References_ ___________________________________________________ 38
Case Vignette Group 10. Leading Causes of Error in Post Anesthesia Care
Unit Records....................................................................................................20
section 4 << 85
section 4
Table 4-4. Node Associated with Post Anesthesia
Care Unit Records by Population...................................................................12
Findings...........................................................................................................27
section 4
Background
The Post Anesthesia Care Unit (PACU) is a critical care area providing Phase
I nursing care for patients immediately following local, regional, and general
anesthesia associated with operative or invasive procedures. With recent
advances in pain management and more ambulatory procedures being performed, PACUs can be high-volume areas with fast turnover of patients.
PACUs are normally staffed by registered nurses with a wide range of backgrounds and expertise in areas such as critical care; plastic surgery; and emergency, orthopedic, cardiology, and gynecologic nursing. This experience
accommodates the wide range of patients passing through the PACU with
procedures ranging from open heart surgery, to radiographic and endoscopic
procedures. The short turnaround time of patients and the non-responsive
or unconscious state of the majority of patients requires greater observation and monitoring to ensure a risk free and safe experience in the PACU.
Postanesthetic management of the patient includes frequent assessments, interventions, and monitoring of respiratory and cardiovascular functions (including hydration status), neuromuscular functions, mental status, pain status, nausea and vomiting, drainage and bleeding, and urinary output.
At the end of successful Phase I care, patients can be transferred to another
clinical area for Phase II recovery to be sent home. PACU is a dynamic location that plays a key role in optimizing patient safety, recovery, and satisfaction
and is an important area that requires considerable support from an institutional perspective.1
In April, 2004 The American Society of PeriAnesthesia Nurses (ASPAN) adopted a position statement addressing safe medication administration.2 This
statement signals that safe medication administration is a core competency for
staff working in this environment. Staff members are also encouraged to know
and implement evidenced-based facility policies related to medication usage,
which, ideally resulted from collaboration between physicians, pharmacists, and
nurses. The American Society of PeriAnesthesia Nurses (ASPAN)2 also has a
standard of care that is aimed to promote and maintain a safe, comfortable, and
therapeutic environment for patients, staff, and visitors. The rationale for this
standard is based on patients receiving sedatives/analgesia agents or anesthetics agents and the effect these agents have on motor and/or sensory function.
The ASPAN Pain & Comfort Resource Manual provides guidelines and other
supporting strategies intended to complement organizational policies and procedures to ensure that patients are cared for according to published standards.3
Pain management for children requires an extra level of caution especially
when providing split doses and doses based on weight in kilograms.
In an earlier study that examined Post Anesthesia Care Unit medication errors
between August, 1998 and March, 2002, as reported to MEDMARX, researchers found that 6.9% of the errors resulted in harm.4 In an Australian Incident
Monitoring Study (AIMS), the outcomes of 419 adverse events, including medication errors, ranged from minor to major, including nine deaths. In the AIMS
study all age ranges were affected by adverse events. One quarter of the events
resulted in hospitalization and most of the patients hospitalized had respiratory
failure.
Findings
Between September 1, 1998, and August 31, 2005 there were 397 facilities
reporting errors that originated in the Post Anesthesia Care Unit (Technical
Appendix 1). Collectively, these facilities submitted 3,260 records with 5.6% (n
= 184) being reported as harmful (Tables 4-1 and 4-2). Errors were reported
across each of the nine possible error categories and 11 cases were classified
as sentinel events (Categories G, H, or I). Of the total errors submitted (n =
3,260), there were 59 records (1.8%) involving a pediatric patient (from 42
facilities). There were 1,135 records (34.8%) involving an adult patient from
287 facilities and 613 (18.8%) records involving a geriatric patient (from 215
facilities). A higher percentage of harmful records were reported in the pediat-
Table 4-1. Distribution of Post Anesthesia Care Unit Records by Error Category Index
section 4
section 4 << 87
Table 4-2. Comparison of Post Anesthesia Care Unit Medication Errors by Error Category Index and Population
All Records
Error Category
Pediatric
Adult
Geriatric
Age not Provided
A
n
237
%
7.3
n
0
%
0
n
0
%
0
n
0
%
0
n
237
%
16.3
B
914
28
0
0
1
0.1
0
0
913
62.8
15.9
C
1,506
46.2
40
67.8
818
72.1
417
68
231
D
419
12.9
7
11.9
218
19.2
143
23.3
51
3.5
E
155
4.8
10
16.9
82
7.2
46
7.5
17
1.2
F
18
0.6
0
0
11
1
4
0.7
3
0.2
G
2
0.1
0
0
1
0.1
1
0.2
0
0
H
7
0.2
2
3.4
3
0.3
1
0.2
1
0.1
I
2
0.1
0
0
1
0.1
1
0.2
0
0
Total Records
3,260
Percent Harmful
59
5.8
1,135
20.3
613
8.7
1,453
8.8
1.4
section 4
ric population compared to the adult or geriatric populations (20.3% compared
to 8.7% or 8.8%. A comparative listing of the findings appears in Technical
Appendix 2.
Two differences are noted between the original MEDMARX study and this
study. First, and perhaps more important, practitioners are now reporting
more Category A and B errors (about 33%) compared to the original study of
only 19.4%. Having more errors reported in Categories A through D not only
increases the percentage of nonharmful errors but also decreases the percentage
of harmful errors (Categories E through I).
The second notable difference since the original study is that an additional
seven reports were classified either as Category G, H, or I, indicating sentinel
events. This should not be construed as signifying that patients are less safe,
but rather, the willingness on the part of facilities to openly share experiences,
in hopes of preventing future errors. Examples of these sentinel events are provided in Table 4-3.
The increase in the number of facilities reporting (from 189 to 354) validates
that errors are not isolated occurrences limited to just one facility, but rather
continues to show that breeches in the medication use process are common.
Table 4-3. Examples of Sentinel Event Medication Errors in PACU
section 4
section 4 << 89
section 4
Table 4-3. Examples of Sentinel Event Medication Errors in PACU
Node of the Medication Use Process
Following surgery, immediate post operative care is inclusive of assessing the
patient for surgery complications (i.e., bleeding), evaluating the cardiac and
respiratory system (for effects of anesthesia and/or surgery), and assessing or
implementing pain control (comfort) measures. In the PACU, the surgeon
and anesthesia provider provide post-operative orders and many patients are
unable to initially participate in their care as they emerge from the effects of
anesthesia. In PACU, the medication use process (MUP) is a multi-disciplinary
process with six unique phases (i.e., Procurement, Prescribing, Documenting/
Transcribing, Dispensing, Administering, and Monitoring)5 that complements
patient care activities. Each phase has both structures and processes associated
with professional responsibilities that minimize the risk of a medication error.
Many routine medications are available through unit stock or from automated
dispensing devices, and as such, bypass order review by pharmacy.
tion readily available or having a lack of personnel on duty with an appropriate
skill mix necessary for treating the breadth of patients in the PACU. Active
failures involve human mistakes, such as writing an order incorrectly, dispensing the wrong drug, or miscalculating the dose for administration.
Findings
Based on 3,023 records, one half of the PACU medication errors originated in
the Administering phase of the medication use process (Table 4-4). Many of
these errors involved giving the wrong dose of medications. This finding was
also observed in each of the populations. The next largest group of errors was
associated with the Prescribing phase of the medication use process and many
of these errors resulted from incorrect or incomplete orders, or orders that contained medications for which the patient had a documented allergy. Errors also
involved the remaining nodes of the MUP, however, in rather limited numbers
and percentages.
There are active and latent failures within the medication use process that lead
to a medication error. Latent failures include having insufficient drug informa-
All Records
Node
Pediatric
Adult
Geriatric
Age not Provided*
Administering
n
1,521
%
50.3
n
49
%
62.8
n
751
%
66.2
n
411
%
67
n
310
%
25.9
Prescribing
858
28.4
18
23.1
179
15.7
88
14.4
573
47.9
Transcribing/Documenting
370
12.2
4
5.1
110
9.7
68
11.1
188
15.7
Dispensing
220
7.3
6
7.7
69
6.1
29
4.7
116
9.7
Monitoring
54
1.8
1
1.3
26
2.3
17
2.7
10
0.8
Total
3,023
78
1,135
613
1,197
* For Categories A & B, age is not required. For Categories C – I, age
was not entered.
section 4 << 91
section 4
Table 4-4. Node Associated with Post Anesthesia Care Unit Records by Population
Background
The Type of Error field is a multi-select field that reporters use to characterize or describe a medication error, regardless of the cause(s). Researchers
involved in the Australian study highlighted the importance of the PACU and
the potential for serious adverse events that may occur there.1 These researchers found drug errors in 11% (n = 44) of the sample, with two errors requiring
life-sustaining intervention. Inappropriate drug prescribing (4%) and overdosage of the prescribed product (3%) were the most common type of drug errors
found. Wrong route errors, due to misconnection of tubing, were present in
three cases. The researchers felt that all of the drug errors were preventable and
suggested that technology (i.e., automated dispensing devices and bar-coding)
would aid in the elimination of future errors.
section 4
Findings
At least one Type of Error was selected in 3,097 Post Anesthesia Care Unit
records. For all records, the four selections most often chosen (Prescribing
error, Improper dose/quantity, Omission error, and Unauthorized/wrong
drug) comprised 79.1% of the selections (Table 4-5). The highest percentage of medication errors from the Post Anesthesia Care Unit sample involves
these four selections. This is consistent with other published MEDMARX data
reports6, 7 and with a prior study4 where the four major types were Omission
error, Unauthorized/wrong drug, Prescribing error and Improper dose/quantity. These findings are also consistent with the Australian findings sited previously.1
Prescribing errors often involved ordering medications for which an allergy
had been previously documented. Some Prescribing errors resulted from misuse of pre-printed order forms. For example, prescribers used routine post-op
orders that included orders for morphine when the patient’s history and chart
indicated a pre-existing allergy to morphine. The Omission errors were usually related to antimicrobial agents. Improper dose/quantity errors most often
involved analgesia medications and involved the use of a patient controlled
analgesia (PCA) device. In many of these cases, the PCA pump was incorrectly
programmed and delivered the wrong amount.
The error descriptions for Wrong route errors revealed that products intended
for one route of administration (i.e., intravenous) were inadvertently given via
another route (i.e., epidural). These errors were the result of tubing compatibility also referred to as “inter-connectedness” or “inter-connectivity”. Though
there were fewer pediatric errors than any other population, the profile of the
types of errors involved in the medication errors varies slightly from the overall
profile. The leading type of error in this population was an Improper dose/
quantity (38.7%) which suggests that the patient received the wrong amount
of the intended product. The text description of these errors signals that, in
some instances, infusion pumps were programmed incorrectly, while in other
instances, there was confusion between dose (i.e., 1 mg) and volume (i.e., 1
mL). Prescribing errors (14.7%) were the second most commonly reported
type of error and were often associated with prescribing products for which
a documented allergy was known. Three other selections (Omission error,
Unauthorized/wrong drug, and Extra dose) were equally reported in 13.3% of
the events.
The adult and geriatric populations look similar to errors overall in terms of the
leading types of errors. Omission errors were the most common type of error
reported in these two populations, 23.8% and 25.9% respectfully.
The highest percentage of Wrong administration technique errors occurred in
the adult population.
The Cause of Error is a multi-select field that reporters use to associate
the events that lead to the error. From early work done by the National
Coordinating Council for Medication Error Reporting and Prevention (NCC
MERP), major causes of errors were determined: communication, name confusion, human factors, storage, packaging and labeling, systems errors, contraindications, and equipment-related. Each of these “parent” groupings contains
other selections (“children”) that provide a more descriptive nature of what
caused the error. In addition to the NCC MERP selections, MEDMARX offers
reporters additional selections that are relevant to medication errors.
Table 4-5. Types of Errors Associated with Post Anesthesia Care Unit Records
All Records
Type of Error
Pediatric
Adult
Geriatric
Age not Provided*
%
n
%
n
%
n
%
n
%
Prescribing error
742
24
11
14.7
164
15
71
12
496
37.1
658
21.2
29
38.7
253
23.1
138
23.4
238
17.8
Omission error
595
19.2
10
13.3
261
23.8
153
25.9
171
12.8
456
14.7
10
13.3
180
16.4
103
17.5
163
12.2
Wrong time
171
5.5
4
5.3
67
6.1
39
6.6
61
4.6
Extra dose
147
4.7
10
13.3
63
5.7
38
6.4
36
2.7
140
4.5
2
2.7
51
4.7
22
3.7
65
4.9
138
4.5
2
2.7
60
5.5
28
4.7
48
3.6
Wrong patient
117
3.8
2
2.7
26
2.4
10
1.7
79
5.9
Wrong route
52
1.7
1
1.3
21
1.9
9
1.5
21
1.6
Wrong dosage form
29
0.9
0
0
10
0.9
5
0.8
14
1
23
0.7
0
0
1
0.1
2
0.3
20
1.5
Expired product†
11
0.4
0
0
1
0.1
1
0.2
9
0.7
7
0.2
0
0
1
0.1
2
0.3
4
0.3
 
81
 
Mislabeling†
3,286
Number of Records
3,097
75
1,159
1,096
 
621
590
 
1,425
1,336
section 4 << 93
section 4
n
section 4
Case Vignettes Group 9: Leading Types of Errors from Post Anesthesia Care Unit Records
Case Vignettes Group 9: Leading Types of Errors from Post Anesthesia Care Unit Records
section 4
section 4 << 95
In the Australian study that reviewed PACU events, the researchers reported
that errors of judgement (18%), communication (14%), fault of technique (7%),
and inadequate patient assessment (7%) were leading causes of adverse events.1
three selections were also the most common selections when cause of error was
examined by pediatric, adult, and geriatric patients. For pediatric events, the
selection Calculation error is notable. The full findings appear in Technical
Appendix 5.
Findings
Other notable selections in the PACU data set include the selection Pump,
improper use (5%), which is considerably higher than what has traditionally
been reported to MEDMARX (~1%)1. Another selection, Contraindicated,
drug allergy (6.2%) is also somewhat higher than the historical data (~ 2%).
section 4
Nearly 96% (n=3,128) of the PACU records identified at least one cause of error
selection and many identified more than one, as evidenced by the total selection count of 5,853. The three leading selections identified were Performance
deficit, Procedure/protocol not followed, and Communication. Together, these
selections were present in nearly 83% of the records (Table 4-6). Many times,
Performance deficit was co-selected with at least one other selection. These
1
See Technical Appendix 14 for historical information.
Table 4-6. Leading Causes of Error in PACU Records, by Population
All records
Cause of Error
Dosage form confusion
Percentages based on Number of
records:
Adult
Geriatric
Age not Provided*
n
%
n
%
n
%
n
%
n
%
1,296
813
486
354
338
194
194
188
155
152
148
140
116
113
86
83
79
76
76
41.4
26
15.5
11.3
10.8
6.2
6.2
6
5
4.9
4.7
4.5
3.7
3.6
2.7
2.7
2.5
2.4
2.4
36
23
17
12
5
1
8
2
1
2
2
1
1
1
0
12
0
1
3
47.4
30.3
22.4
15.8
6.6
1.3
10.5
2.6
1.3
2.6
2.6
1.3
1.3
1.3
0
15.8
0
1.3
3.9
523
319
210
115
123
93
51
71
93
45
63
31
20
43
8
27
18
26
24
47.5
29
19.1
10.5
11.2
8.5
4.6
6.5
8.5
4.1
5.7
2.8
1.8
3.9
0.7
2.5
1.6
2.4
2.2
296
177
118
57
62
44
29
39
47
29
34
21
14
38
2
24
10
11
13
50.3
30.1
20.1
9.7
10.5
7.5
4.9
6.6
8
4.9
5.8
3.6
2.4
6.5
0.3
4.1
1.7
1.9
2.2
441
294
141
170
148
56
106
76
14
76
49
87
81
31
76
20
51
38
36
32.3
21.6
10.3
12.5
10.9
4.1
7.8
5.6
1
5.6
3.6
6.4
5.9
2.3
5.6
1.5
3.7
2.8
2.6
51
1.6
3
3.9
14
1.3
8
1.4
26
1.9
3,128
76
1,100
588
1,364
section 4 << 97
section 4
Performance deficit
Procedure/protocol not followed
Communication
Knowledge deficit
Documentation
Contraindicated, drug allergy
Written order
Pump, improper use
Preprinted medication order form
Computer entry
System safeguard(s)
Abbreviations
Calculation error
Handwriting illegible/unclear
Verbal order
Pediatric
section 4
Case Vignette Group 10. Leading Causes of Error in Post Anesthesia Care Unit Records
Reason’s work views the origin of errors as consequence of “upstream” or “systemic” factors.8 Factors that contribute to errors include organizational (also
known as latent) factors, situational, and environmental. Australian researchers
have reported the occurrence of such factors in the generation of the medical
incidents occurring in PACU1. For example, inattention/distractions (3.2%),
inexperience (2%), and haste (2%) were present in their study of adverse events.
Bed shortages (1%) and inadequate equipment and supplies (2.5%) were also
noted. For safe medication practices to occur, practitioners must begin to
recognize and address how these factors negatively impact practice. The 2004
Standards of Perianesthesia Nursing9 includes a position statement for safe
medication administration that addresses many of these factors. This statement
calls for post-anesthesia areas to “restrict unnecessary noise and distractions
from the medication preparation area” (p.91). From an organizational perspective, PACUs are encouraged to have equipment and space dedicated to the caring for the population served and document skill-set competencies of employes, all actions consistent with the 2004 Standards of Perianesthesia Nursing.9
Findings
list became mandatory in 2003. Given this change in the MEDMARX program,
only slightly more than one third of the PACU records were associated with at
least one contributing factor. The selection None was most commonly reported for all records and it was followed by the selection Distractions (Table 4-7).
Together, these two selections were present in more than half of the records.
One selection (Patient names similar/same) was not associated with any PACU
records.
Slightly more than half of the pediatric records (33 out of 59) noted at least one
contributing factor. The pediatric records also had the least selections (10 out
of 20) associated with medication error records. The selections None and Staff,
inexperienced were reported at 27.3% and 21.2%, respectfully. Distractions
were associated with nearly one quarter (24.2%) of the records. For adult medication errors, the two leading selections were None and Distractions, a finding
that was also present in the geriatric population. The comparative data findings
are presented in Technical Appendix 6.
section 4
section 4 << 99
Table 4-7. Contributing Factors associated with Post Anesthesia Care Unit
All Records
 Contributing Factor
%
n
Adult
%
n
Geriatric
%
n
Age not Provided*
%
n
%
None
513
42.3
9
27.3
171
35
86
37.2
247
53.5
Distractions
289
23.8
8
24.2
125
25.6
61
26.4
95
20.6
113
9.3
7
21.2
50
10.2
15
6.5
41
8.9
94
7.7
1
3
41
8.4
16
6.9
36
7.8
Workload increase
section 4
n
Pediatric
Patient transfer†
90
7.4
4
12.1
45
9.2
22
9.5
19
4.1
Cross coverage
75
6.2
0
0
30
6.1
20
8.7
25
5.4
56
4.6
1
3
23
4.7
14
6.1
18
3.9
Shift change
39
3.7
2
6.1
20
4.1
11
4.8
6
1.3
Emergency situation
27
2.2
0
0
10
2
10
4.3
7
1.5
27
2.2
1
3
16
3.3
4
1.7
6
1.3
15
1.2
0
0
7
1.4
6
2.6
2
0.4
Staff, floating
12
1
0
0
8
1.6
2
0.9
2
0.4
No 24-hour pharmacy
10
0.8
1
3
4
0.8
2
0.9
3
0.6
Imprint, identification failure†
9
0.7
0
0
5
1
1
0.4
3
0.6
8
0.7
0
0
4
0.8
1
0.4
3
0.6
6
0.5
0
0
2
0.4
1
0.4
3
0.6
Poor lighting
3
0.2
1
3
0
0
2
0.9
0
0
Code situation
2
0.2
0
0
0
0
1
0.4
1
0.2
Range orders†
2
0.2
0
0
0
0
0
0
2
0.4
Patient names similar/same†
0
0
0
0
0
0
0
0
0
0
1,390
 
35
 
561
 
275
 
519
Number of Records
1,214
33
488
231
462
Case Vignette Group 11: Contributing Factors with Post Anesthesia Care Unit Records
Contributing
Factor
Patient Transfer
Error Description
An order was written for dolasteron to be given for
nausea while the patient was in the PACU. The
order was processed through the Computerized
Prescriber Order Entry (CPOE) system with a comment field of “Give in PACU only”. The patient was
transferred to the patient care unit and still had
nausea. The nurse on the patient care unit saw the
dolasteron as an active order and gave a subsequent dose.
Error Category
Node
Index
C
An error occurred
that reached the
patient but did
not cause patient
harm
Administering
Type of
Error
Unauthorized/
wrong drug
Cause of
Error
Computerized
prescriber
order entry
Product
Patient’s
age
Dolasteron
71 years
Actions Taken following a Medication Error:
Patient safety is advanced by understanding, supporting, and reinforcing provider’s ability to detect and report errors and represents an opportunity for performance improvement.10 An organization’s culture, through the actions of its
managers, significantly influences what happens after an event occurs. Today’s
patient safety programs must ensure that all actions taken have lasting effects
on the practice environment. Evaluating medication errors is one means of
ensuring that patients are provided excellence in care. Professional staff working in the PACU monitors and evaluates perianesthesia care on an ongoing
basis.9 Any plan must be integrated into the overall organizational program
and identify issues, implement resolutions, and assess the effectiveness through
continual monitoring.
Nearly two-thirds of the records documented a specific action taken resulting
from the error (Table 4-8). The majority of the selections involved actions
aimed at individuals (i.e., Informed staff who made the initial error, Informed
staff who was also involved in the error, Communication process enhanced,
or Education/training provided). Few records addressed systems-level issues
(i.e., Environment modified, Policy/Procedure changed, Staffing practice/policy
modified, or Computer software modified/obtained).
section 4 << 101
section 4
Findings
Table 4-8. Actions Taken as Reported in Post Anesthesia Care Unit Records, By Populations.
section 4
Actions Taken
All Records
n
%
Pediatric
n
%
Adult
n
%
Geriatric
n
%
Age not Provided*
n
%
Informed staff who made the initial error
933
55
24
70.6
359
57.7
186
57.8
364
50.7
Education/Training provided
361
21.3
11
32.4
113
18.2
68
21.1
169
23.5
Informed staff who was also involved in error
360
21.2
10
29.4
154
24.8
78
24.2
118
16.4
None
218
12.9
2
5.9
89
14.3
43
13.4
84
11.7
Communication process enhanced
211
12.4
8
23.5
87
14
35
10.9
81
11.3
207
12.2
3
8.8
97
15.6
41
12.7
66
9.2
Informed patient/caregiver of medication error
63
3.7
3
8.8
33
5.3
15
4.7
12
1.7
26
1.5
2
5.9
10
1.6
6
1.9
8
1.1
Staffing practice/policy modified
22
1.3
2
5.9
10
1.6
3
0.9
7
1
20
1.2
2
5.9
7
1.1
0
0
11
1.5
13
0.8
1
2.9
5
0.8
4
1.2
3
0.4
Computer software modified/obtained
9
0.5
0
0
0
0
0
0
9
1.3
Formulary changed
2
0.1
0
0
1
0.2
0
0
1
0.1
2,445
 
68
 
965
 
479
 
933
Number of Records
1,696
34
622
322
718
* For Categories A & B, age is not required. For Categories C – I,
age was not entered.
Products Involved in Medication Errors
A variety of products are needed to care for PACU patients, ranging from
analgesia medications, antimicrobial agents, intravenous fluids, and respiratory products. In many cases, the PACU may initiate the post-operative orders
and administer the first dose. Given the breadth of the patients cared in this
area, having ready access to those products is important. Equally important is
the ability to involve pharmacy personnel in reviewing non-emergent orders.
Given the high utilization of patient controlled analgesia use in this area, staff
members must be familiar with the various devices to ensure safety.
Findings
Between September 1, 1998, and August 31, 2005, there were 2,874 Post
Anesthesia Care Unit records associated with 3,312 product selections, indicating that some medication error events involved more than one product (Table
4-9). These records contained 366 unique product selections2. For the 76
pediatric records, there were 86 product selections encompassing 38 different
products. In the adult records (n = 1,063), there were 1,189 product selections
All dosage forms and formulations of the same generic name are combined to form a product
selection
spanning 185 unique products. Geriatric records (n = 579) contained 650
selections and 145 products.
For harmful records, 57 products were identified and the leading four included
‘high-alert’ central nervous system products used for analgesia (Table 4-10).
Regardless of the patient’s age for both non-harmful and harmful errors, medication errors were predominantly associated with analgesic products and antimicrobial agents (Table 4-10).
Upon review of the text associated with many of the records, several themes
emerged that predispose patients to risk and harm. These included: tubing
connectivity errors, patient-controlled analgesia errors, and errors involving
the wrong amount of drug being given due to confusion between dosage and
volume.
Tubing connectivity errors were noted when medications intended for parenteral administration (e.g. intravenous piggybacks) were found to have been
connected to epidural lines, resulting in wrong route errors. Another connectivity issue indicated that intravenous fluid was found infusing into indwelling
bladder catheters.
Another common theme identified was confusion between volume and dose.
For example 0.1 mg of product was prescribed but 0.1 mL was given. This type
of error was most prevalent when errors involved the pediatric population.
Extra attention to detail must be encouraged when children are involved. A
miscalculation of dosage can lead to triple-fold overdoses and serious harm to
an already compromised child.
Each of these three issues is a high risk, problem prone area that should be
explored through a Failure Modes and Effects Analysis or other intervention.
The MEDMARX data pertaining to products involved in errors highlights the
diversity of products used in post-anesthesia care and points to the need for
having current references, inclusive of drug dosing guidelines, readily available.
section 4 << 103
section 4
Patient controlled analgesia (PCA) is a term that is commonly used to describe
a method of pain relief which uses disposable or electronic infusion devices and
allows patients to self-administer analgesic drugs, most commonly, through
the intravenous (IV) route of administration.11 The order for PCA includes
parameters that are programmed into electronic devices (i.e., the pumps), and
includes bolus dose, lockout interval, dose limits, and basal (or background)
infusion.11 Based on the textual descriptions in the MEDMARX data, errors
were common with the use of PCA pumps. Some cases described the practitioner incorrectly completing a pre-printed order form and selecting the wrong
product. Administering errors were often common in the setup phase of PCA
pumps. Errors occurred with selecting the wrong product from inventory (i.e.,
morphine instead of hydromorphone), selecting the wrong bolus amount, or
programming the wrong infusion rate. Some case reports indicated that the
pump was properly set up but the tubing never connected to the patient, leading to the omission of pain medicine.
Table 4-9. Most Commonly Reported Products Involved in Overall (Categories A–I) Post Anesthesia Care Unit Errors Generic Name
Morphine*
Meperidine
Cefazolin
Hydromorphone
Fentanyl*
Ketorolac
Heparin*
Promethazine
Oxycodone and
Acetaminophen
Potassium
Chloride*
Bupivacaine
Insulin*
section 4
Midazolam
Acetaminophen
Metoclopramide*
Hydrocodone
and
Acetaminophen
Ampicillin and
Sulbactam
Levofloxacin
Oxycodone
All Records
n
%
582
17.6
215
6.5
210
6.3
200
6.0
147
4.4
Generic Name
Morphine*
Acetaminophen
Meperidine
Cefazolin
Acetaminophen
and
Codeine
133
4.0
74
2.2
Fentanyl*
69
2.1
Ampicillin and
Sulbactam
61
1.8
44
1.3
43
1.3
38
1.1
37
1.1
36
1.1
31
0.9
Dextrose 5% in
Water
and Lactated
Ringer’s
Diphenhydramine
Ketorolac
Lactated Ringers
Injection
Pediatric
n
%
17
19.8
12
14.0
7
8.1
5
5.8
4
4.7
4
4.7
2
2.3
Generic Name
Morphine*
Meperidine
Hydromorphone
Cefazolin
Ketorolac
Fentanyl*
Promethazine
Heparin*
Estradiol
Vancomycin
Oxycodone and
Acetaminophen
2
2.3
2
2.3
Potassium
Chloride*
2
2.3
Bupivacaine
Insulin*
2
2.3
Hydrocodone
and
Acetaminophen
28
0.8
Metoclopramide*
27
0.8
Gentamicin
26
0.8
Ondansetron
25
0.8
Cefoxitin
Adult
n
%
255
21.4
91
7.7
81
6.8
74
6.2
72
6.1
44
3.7
30
2.5
26
2.2
21
1.8
21
1.8
16
1.3
16
1.3
15
1.3
15
1.3
13
1.1
13
1.1
10
0.8
10
0.8
10
0.8
Generic Name
Morphine*
Cefazolin
Hydromorphone
Meperidine
Fentanyl*
Heparin*
Ketorolac
Vancomycin
Potassium
Chloride*
Metoprolol
Tartrate
Bupivacaine
Diltiazem
Enoxaparin
Oxycodone and
Acetaminophen
Albuterol
Insulin*
Levofloxacin
Metronidazole
Nitroglycerin*
Geriatric
n
%
129
19.7
52
8.0
37
5.7
35
5.4
29
4.5
27
4.2
20
3.1
12
1.8
10
1.5
8
7
7
7
1.2
1.1
1.1
1.1
7
6
6
6
6
6
1.1
0.9
0.9
0.9
0.9
0.9
and 145 unique products
Table 4-10. Most Commonly Reported Products Involved in Harmful (Categories E–I) Post Anesthesia Care Unit Errors All Records
n
%
52
26.1
20
10.1
17
8.5
15
7.5
10
5.0
6
3.0
4
2.0
4
2.0
4
2.0
4
2.0
4
3
3
2.0
1.5
1.5
3
3
3
2
2
1.5
1.5
1.5
1.0
1.0
2
1.0
Generic Name
Morphine*
Meperidine
Hydralazine
Metoclopramide*
Midazolam
Vancomycin
Pediatric
n
%
6
50.0
2
16.7
1
8.3
1
8.3
1
8.3
1
8.3
Generic Name
Morphine*
Hydromorphone
Meperidine
Fentanyl*
Ketorolac
Oxycodone and
Acetaminophen
Bupivacaine*
Cefazolin
Heparin*
Hydrocodone
and
Acetaminophen
Epinephrine*
Mannitol
Midazolam
Naloxone
Phenylephrine*
Adult
n
%
22
19.8
13
11.7
10
9.0
9
8.1
5
4.5
4
3
3
3
3.6
2.7
2.7
2.7
3
2
2
2
2
2
2.7
1.8
1.8
1.8
1.8
1.8
Generic Name
Morphine*
Meperidine
Heparin*
Fentanyl*
Insulin*
Hydromorphone
Naloxone
Geriatric
n
%
20 33.9
6 10.2
5
8.5
4
6.8
3
5.1
2
3.4
2
3.4
Based on 51 records, 59
selections, and
24 unique products
and
6 unique products
and
57 unique products
section 4 << 105
section 4
Generic Name
Morphine*
Meperidine
Hydromorphone
Fentanyl*
Heparin*
Ketorolac
Bupivacaine
Insulin*
Midazolam
Naloxone
Oxycodone and
Acetaminophen
Cefazolin
Epinephrine*
Hydrocodone
and
Acetaminophen
Metoclopramide*
Propofol
Mannitol
Phenylephrine*
Propoxyphene
and
Acetaminophen
Table 4-11. Leading Types of Errors and Products Involved
Type of Error
Prescribing error
Omission error
section 4
Wrong time
Product
Morphine*
Cefazolin
Hydromorphone*
Meperidine*
Promethazine
Morphine*
Hydromorphone*
Meperidine*
Fentanyl*
Heparin*
Cefazolin
Morphine*
Ketorolac
Hydromorphone*
Estradiol
Morphine*
Meperidine*
Hydromorphone*
Cefazolin
Ketorolac
Cefazolin
Ketorolac
Morphine*
Heparin*
Vancomycin
Error Result on Level of Patient Care:
Medication errors can have unintended consequences for the patient, such as
delaying discharge from the PACU or requiring unexpected hospitalization.
Some errors may require additional interventions, such as lab or extra monitoring, to preclude harm. Added interventions come at a cost, both to the patient
and the organization. As the seriousness of the medication error escalates,
there is often a corresponding increase in resources required.
Findings
The Error Result on Level of Patient Care was relevant for errors that reached
the patient (Categories
n
140
47
45
37
31
153
71
49
48
26
98
64
28
22
17
106
62
30
20
16
24
12
10
8
8
C–I). The majority of records (56.3%) indicated that no additional care was
rendered to the patient following the error (Table 4-12), a finding that was
fairly constant for all populations reviewed. Another consistent finding across
the data set was Drug therapy initiated/changed.
As a percentage, the selection Observation initiated/increased was highest in
pediatric population. Narcotic antagonist administered was highest in the pediatric population, which is consistent given the leading type of error (improper
dose/quantity) and the high-alert narcotic products involved in the errors.
Given the nature of the errors, many of the selections are clinically valid
responses.
Table 4-12. Level of Care Rendered as a Result of the Error All
Level of Care
Adult
Age not
n
%
n
%
n
%
n
%
n
%
None
792
56.3
30
48.4
496
59.8
235
52.6
31
44.9
282
20
11
17.7
173
20.9
89
19.9
9
13
255
18.1
14
22.6
128
15.4
96
21.5
17
24.6
9.8
12
19.4
66
8
50
11.2
10
14.5
46
3.3
1
1.6
18
2.2
21
4.7
6
8.7
40
2.8
6
9.7
19
2.3
14
3.1
1
1.4
30
2.1
4
6.5
15
1.8
11
2.5
0
0
Oxygen administered
26
1.8
7
11.3
9
1.1
8
1.8
2
2.9
23
1.6
3
4.8
4
0.5
13
2.9
3
4.3
21
1.5
1
1.6
8
1
8
1.8
4
5.8
Hospitalization, prolonged 1-5 days
8
0.6
1
1.6
6
0.7
1
0.2
0
0
5
0.4
3
4.8
1
0.1
0
0
1
1.4
CPR administered
5
0.4
1
1.6
3
0.4
1
0.2
0
0
5
2
0.4
0.1
0
0
0
0
2
2
0.2
0.2
3
0
0.7
0
0
0
0
0
Surgery performed
2
0.1
0
0
2
0.2
0
0
0
0
Blood product infusion
1
0.1
0
0
0
0
1
0.2
0
0
Cardiac defibrillation performed
1
0.1
0
0
1
0.1
0
0
0
0
1,682
 
94
 
953
 
551
 
84
X-ray, CAT, MRI, or other diagnostic test(s) performed
* For Categories A & B, age is not required. For Categories C – I,
age was not entered.
section 4 << 107
section 4
138
Summary of Post Anesthesia Care Unit Medication Errors
This practice area fulfills the standard put forth by the American Society of
Anesthesiologists9 in that Post Anesthesia Care Units are areas designated to
receive patients following anesthesia for the purposes of continual monitoring
of the patient’s condition. This Report begins to identify and address recurring problems that threaten patient safety in the Post Anesthesia Care Units.
Priority areas USP recommends for further multi-disciplinary investigation
include:
•
Using the FMEA approach, develop explicit heuristic educational and
training strategies that ensure the safe use of intravenous and epidural patient
controlled analgesia pumps,
•
Requiring forcing functions be developed by vendors and adopted by
healthcare systems that prevent tubing misconnections
•
Ensuring that calculations are accurate throughout the medication use
process by providing weight conversion charts and maximum dosing charts,
section 4
•
Adhering to appropriate staffing guidelines as directed by the patient
population served,
•
Reducing the potential for dose-versus-volume errors (i.e., 0.6 mg versus 0.6 mL) through obtaining products in the final ready-to-use dose.
•
Translating the principles of ASPAN’s position statement on Safe
Medication Administration into practice,
•
Dedicating pharmacy personnel to support PACU that review all
medication orders, evaluate medications routinely stocked in the area, assist
with the medication reconciliation process, and assist with obtaining standardized dosing to the extent possible.
•
Ensuring the elimination of abbreviations for compliance with
National Patient Safety Goals.
•
Encouraging reporting of medication errors and other adverse events
in order to learn from the errors.
References
1.
Kluger MT, Bullock MF. Recovery room incidents: a review of 419
reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia.
Nov 2002;57(11):1060-1066.
2.
The American Society of PeriAnesthesia Nurses. 2004 Standards of
Perianesthesia Nursing. Cherry Hill, NJ 2004.
3.
The American Society of PeriAnesthesia Nurses. ASPAN pain & comfort resource manual, 2003-2004. Cherry Hill, NJ.
4.
Hicks RW, Becker SC, Krenzischeck D, Beyea SC. Medication
errors in the PACU: A secondary analysis of MEDMARX findings. Journal of
Perianesthisa Nursing. 2004;19(1):18-28.
5.
6.
Hicks RW, Cousins DD, Williams RL. Summary of information submitted to MEDMARX in the year 2002. The quest for quality. Rockville, MD:
United States Pharmacopeia; 2003.
7.
Rockville, MD: The United States Pharmacopeia Center for the Advancement
of Patient Safety; 2004.
8.
Reason J. Human error. New York City: Cambridge University; 1990.
9.
The American Society of PeriAnesthesia Nursing. 2004 standards of
perianesthsia nursing. Cherry Hill, NJ: American Society of PeriAnesthesia
Nursing; 2004.
10.
11.
Macintyre PE. Safety and efficacy of patient-controlled analgesia.
British Journal of Anaesthesia. 2001;87(1):36-46.
Perioperative Technical Appendices
(Comparative Findings)
Perioperative Technical Appendices.........................................................................................................
Technical Appendix 1. Facility Characteristics.........................................................................................
Technical Appendix 2. Error Category Index,
by Clinical Unit, by Population...................................................................................................................
Technical Appendix 3. Node, by Clinical Unit,
by Population.............................................................................................................................................
Technical Appendix 4. Types of Error, by Clinical Unit,
by Population.............................................................................................................................................
Technical Appendix 5. Causes of Error by Clinical Unit,
by Population.............................................................................................................................................
Technical Appendix 6. Contributing Factors, by Clinical Unit,
by Population.............................................................................................................................................
Technical Appendix 8. Level of Staff Identified Making the Initial Error,
Technical Appendix 9. Publications Utilizing MEDMARX Perioperative Data .........................................
Appendices—Perioperative << 109
Appendices—Perioperative
Technical Appendix 7. Actions Taken as a Result of the Error,
Technical Appendix 1. Facility Characteristics
OPS
Pre-op
PACU
Type of Facility
n
%
n
%
n
%
n
%
Ambulatory or other outpatient clinic
7
1.7
1
0.6
5
1.1
5
1.3
Critical access hospital
17
4.0
3
1.7
13
2.9
6
1.5
General community hospital
354
83.9
151
85.3
375
83.9
340
85.6
Specialty
3
0.7
4
2.3
5
1.1
5
1.3
University hospital
34
8.1
18
10.2
37
8.3
34
8.6
Did not specify
7
1.7
0
0
12
2.7
7
1.8
422
 
177
447
 
397
 
Total
OPS
 
Pre-op
OR
PACU
Owner of Facility
n
%
n
%
n
%
n
%
Governmental; Federal
77
18.2
28
15.8
65
14.5
53
13.4
Governmental; non-Federal
(state/city/county)
38
9.0
17
9.6
48
10.7
39
9.8
Nongovernmental nonprofit
294
69.7
130
73.4
319
71.4
295
74.3
For profit
4
0.9
2
1.1
3
0.7
3
0.8
Did not specify
9
2.1
0
0
12
2.7
7
1.8
422
 
177
 
447
 
397
 
Total
OR
OPS
Pre-op
OR
PACU
Bed Size
n
%
n
%
n
%
n
%
No-bed facility
6
1.4
1
0.6
4
0.9
4
1.0
< 50
82
19.4
28
15.8
78
17.4
56
14.1
50 – 99
57
13.5
18
10.2
59
13.2
49
12.3
100 – 199
103
24.4
45
25.4
106
23.7
101
25.4
200 – 299
74
17.5
36
20.3
84
18.4
81
20.4
300 – 399
45
10.7
21
11.9
46
10.3
43
10.8
>= 400
52
12.3
28
15.8
62
13.9
59
14.9
Did not specify
3
0.7
0
0
8
1.8
4
1.0
422
 
177
 
447
 
397
 
Total
Technical Appendix 2. Error Category Index, by Clinical Unit, by Population
Outpatient Surgery Department
Category
A
All
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
289
9.2
0
0
0
0
0
0
289
%
17.5
B
1,065
24.9
0
0
0
0
0
0
1,065
64.3
C
1,702
54.8
67
79.8
879
81.3
498
82.2
258
15.6
D
272
7.9
14
16.7
147
13.6
77
12.7
34
2.1
E
76
2.5
2
2.4
44
4.1
23
3.8
7
0.4
F
20
0.7
1
1.2
11
1.0
6
1.0
2
0.1
G
0
0
0
0
0
0
0
0
0
0
H
3
0.1
0
0
0
0
2
0.3
1
0.1
I
0
0
0
0
0
0
0
0
0
0
 Total
3,427
 
% Harmful
84
3.3
 
1,081
 
3.6
606
5.1
 
1,656
5.1
 
0.6
Pre-operative Holding Area
Category
All
Pediatric
Adult
Geriatric
Age Not Provided
%
n
%
n
%
n
%
n
%
A
167
21.4
0
0
0
0
0
0
167
45.8
B
177
22.7
0
0
0
0
0
0
177
48.5
C
362
46.5
18
75.0
197
82.4
132
87.4
15
4.1
D
51
6.5
5
20.8
25
10.5
15
9.9
6
1.6
E
16
2.1
1
4.2
11
4.6
4
2.6
0
0
F
5
0.6
0
0
5
2.1
0
0
0
0
G
0
0
0
0
0
0
0
0
0
0
H
1
0.1
0
0
1
0.4
0
0
0
0
I
0
0
0
0
0
0
0
0
0
0
 Total
% Harmful
779
 
2.8
24
 
4.2
239
 
7.1
151
 
2.6
365
 
0
Technical Appendix 2 continued
n
Technical Appendix 2. Error Category Index, by Clinical Unit, by Population (continued)
Operating Room
 Category
All
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
A
557
14.8
0
0
0
0
0
0
557
33
B
769
20.4
0
0
2
0.2
0
0
767
45.5
C
1709
45.3
79
62.7
891
70.0
479
69.5
260
15.4
D
465
12.3
26
20.6
236
18.6
141
20.5
62
3.7
E
220
5.8
14
11.1
115
9.0
56
8.1
35
2.1
F
41
1.1
6
4.8
21
1.7
11
1.6
3
0.2
G
1
0
0
0
1
0.1
0
0
0
0
H
9
0.2
0
0
6
0.5
2
0.3
1
0.1
2
0.1
1
0.8
0
0
0
0
1
0.1
3,773
 
126
 
1,272
1,686
 
I
 Total
% Harmful
7.2
 
16.7
689
11.3
 
n
10.0
%
2.5
Postanesthesia Care Unit
Category
All
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
A
237
7.3
0
0
0
0
0
0
237
16.3
B
914
28.0
0
0
1
0.1
0
0
913
62.8
C
1,506
46.2
40
67.8
818
72.1
417
68.0
231
15.9
D
419
12.9
7
11.9
218
19.2
143
23.3
51
3.5
E
155
4.8
10
16.9
82
7.2
46
7.5
17
1.2
F
18
0.6
0
0
11
1.0
4
0.7
3
0.2
G
2
0.1
0
0
1
0.1
1
0.2
0
0
H
7
0.2
2
3.4
3
0.3
1
0.2
1
0.1
2
0.1
0
0
1
0.1
1
0.2
0
0
3,260
 
59
1,135
 
613
 
1,453
I
 Total
% Harmful
5.9
 
20.3
8.7
8.8
n
%
 
1.5
Technical Appendix 3. Node, by Clinical Unit, by Population
Node
All Records
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Prescribing
928
29.6
11
13.1
127
11.7
71
11.7
719
52.6
Transcribing/ Documenting
358
11.4
9
10.7
100
9.3
59
9.7
190
13.9
Dispensing
261
8.3
4
4.8
88
8.1
53
8.7
116
8.5
1,562
49.8
60
71.4
756
69.9
417
68.8
329
24.0
Monitoring
28
0.9
0
0
9
0.8
6
1.0
13
1.0
Procurement
1
0
0
0
0
0
0
0
1
0.1
Administering
Node
All Records
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Prescribing
73
11.9
1
4.2
18
7.5
12
7.9
42
21.2
134
21.9
3
12.5
17
7.1
16
10.6
98
49.5
Dispensing
44
7.2
1
4.2
16
6.7
9
6.0
18
9.1
Administering
352
57.5
19
79.2
183
76.6
112
74.2
38
19.2
9
1.5
0
0
5
2.1
2
1.3
2
1.0
Monitoring
Technical Appendix 3. Node, by Clinical Unit, by Population (continued)
Operating Room
 Node
All Records
n
%
Pediatric 
n
%
Adult 
Geriatric 
n
%
n
%
Age Not Provided
n
%
Prescribing
646
20.1
28
15.3
189
14.9
87
12.6
342
31.9
325
10.1
11
6.0
108
8.5
62
9.0
144
13.4
Dispensing
372
11.6
15
8.2
93
7.3
57
8.3
207
19.3
1,810
56.3
127
69.4
870
68.4
473
68.7
340
31.7
63
2.0
2
1.1
12
0.9
10
1.5
39
3.6
Administering
Monitoring
Node
All Records
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Prescribing
858
28.4
18
23.1
179
15.7
88
14.4
573
47.9
370
12.2
4
5.1
110
9.7
68
11.1
188
15.7
Dispensing
220
7.3
6
7.7
69
6.1
29
4.7
116
9.7
1,521
50.3
49
62.8
751
66.2
411
67.0
310
25.9
54
1.8
1
1.3
26
2.3
17
2.7
10
0.8
Administering
Monitoring
Technical Appendix 4. Types of Error, by Clinical Unit, by Population
All Records
Type of Error
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Prescribing error
892
27.7
6
7.3
95
9.3
53
9.2
738
47.8
Omission error
761
23.6
23
28.0
361
35.5
188
32.5
189
12.2
633
19.6
29
35.4
129
12.7
85
14.7
390
25.3
461
14.3
9
11.0
183
18.0
107
18.5
162
10.5
Wrong time
206
6.4
5
6.1
91
8.9
46
7.9
64
4.1
131
4.1
4
4.9
42
4.1
36
6.2
49
3.2
Wrong patient
116
3.6
1
1.2
36
3.5
17
2.9
62
4.0
Extra dose
99
3.1
4
4.9
56
5.5
21
3.6
18
1.2
92
2.9
2
2.4
31
3.0
31
5.4
28
1.8
Wrong route
73
2.3
2
2.4
37
3.6
22
3.8
12
0.8
69
2.1
0
0
7
0.7
8
1.4
54
3.5
11
0.3
0
0
4
0.4
0
0
7
0.5
a
Wrong dosage form
a
Expired product
Mislabeling
a
Deteriorated product
8
0.2
0
0
1
0.1
0
0
7
0.5
7
0.2
0
0
3
0.3
1
0.2
3
0.2
3,559
85
1,076
615
1,783
Number of Records
3,223
82
1,018
579
1,544
aSelection not available all years.
Technical Appendix 4. Types of Error, by Clinical Unit, by Population (continued)
All Records
Type of Error
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Wrong time
288
37.7
4
16.7
36
15.1
22
15.0
226
4.2
Omission error
227
29.7
12
50.0
119
49.8
68
46.3
28
13.1
80
10.5
0
0
31
13.0
26
17.7
23
5.0
Prescribing error
80
10.5
1
4.2
17
7.1
9
6.1
53
1.7
53
6.9
3
12.5
22
9.2
16
10.9
12
3.1
18
2.4
2
8.3
6
2.5
3
2.0
7
0.6
Extra dose
16
2.1
0
0
7
2.9
4
2.7
5
0.8
15
2.0
1
4.2
8
3.3
5
3.4
1
1.0
Wrong patient
12
1.6
1
4.2
3
1.3
2
1.4
6
0.4
Wrong route
9
1.2
0
0
6
2.5
1
0.7
2
0.2
4
0.5
0
0
0
0
1
0.7
3
0.2
Wrong dosage form
Mislabeling
a
a
Expired product
Pediatric
a
1
0.1
0
0
0
0
0
0
1
0
1
0.1
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
804
24
255
157
368
Number of Records
764
24
239
147
354
Operating Room
All Records
Type of Error
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Omission error
732
21.4
26
15.0
322
27.3
191
29.7
193
13.6
703
20.6
32
18.5
250
21.2
118
18.3
303
21.3
Prescribing error
581
17.0
16
9.2
158
13.4
78
12.1
329
23.2
543
15.9
56
32.4
172
14.6
99
15.4
216
15.2
249
7.3
11
6.4
75
6.4
58
9.0
105
7.4
Wrong time
208
6.1
14
8.1
82
7.0
39
6.1
73
5.1
Wrong patient
120
3.5
5
2.9
28
2.4
18
2.8
69
4.9
121
3.5
9
5.2
49
4.2
25
3.9
38
2.7
Extra dose
111
3.2
11
6.4
35
3.0
31
4.8
34
2.4
49
1.4
3
1.7
25
  2.1
13
2.0
8
0.6
86
2.5
0
0
6
0.5
1
0.2
79
5.6
0.6
12
1.0
3
0.5
17
1.2
8
0.7
3
0.5
30
2.1
10
0.8
1
0.2
12
0.8
Wrong route
a
Wrong dosage form
a
Expired product
a
Mislabeling
33
1.0
1
41
1.2
0
24
0.7
1
 0
0.6
3,601
185
1,232
678
1,506
Number of Records
3,416
173
1,179
644
1,420
All Records
Type of Error
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Prescribing error
742
24.0
11
14.7
164
15.0
71
12.0
496
37.1
658
21.2
29
38.7
253
23.1
138
23.4
238
17.8
Omission error
595
19.2
10
13.3
261
23.8
153
25.9
171
12.8
456
14.7
10
13.3
180
16.4
103
17.5
163
12.2
Wrong time
171
5.5
4
5.3
67
6.1
39
6.6
61
4.6
Extra dose
147
4.7
10
13.3
63
5.7
38
6.4
36
2.7
140
4.5
2
2.7
51
4.7
22
3.7
65
4.9
138
4.5
2
2.7
60
5.5
28
4.7
48
3.6
Wrong patient
117
3.8
2
2.7
26
2.4
10
1.7
79
5.9
Wrong route
52
1.7
1
1.3
21
1.9
9
1.5
21
1.6
29
0.9
0
0
10
0.9
5
0.8
14
1.0
23
0.7
0
0
1
0.1
2
0.3
20
1.5
11
0.4
0
0
1
0.1
1
0.2
9
0.7
7
0.2
0
0
1
0.1
2
0.3
4
0.3
 
Wrong dosage form
Expired product
Mislabeling
Pediatric
a
a
a
3,286
81
1,159
621
1,425
Number of Records
3,097
75
1,096
590
1,336
Technical Appendix 5. Causes of Error, by Clinical Unit, by Population
All Records
Cause of Error
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
1,354
40.8
34
42.5
524
50.6
298
50.2
498
31
778
23.5
18
22.5
318
30.7
193
32.5
249
15.5
Communication
518
15.6
21
26.3
202
19.5
120
20.2
175
10.9
Knowledge deficit
364
11
7
8.8
80
7.7
56
9.4
221
13.8
Documentation
339
10.2
8
10.0
107
10.3
51
8.6
173
10.8
322
9.7
4
5.0
71
6.9
24
4.0
223
13.9
Performance deficit
a
%
Computerized prescriber order entry
201
6.1
0
0
5
0.5
1
0.2
195
12.1
Written order
169
5.1
4
5.0
50
4.8
26
4.4
89
5.5
157
4.7
7
8.8
35
3.4
30
5.1
85
5.3
Abbreviations
144
4.3
1
1.3
1
0.1
4
0.7
138
8.6
Computer entry
143
4.3
2
2.5
14
1.4
7
1.2
120
7.5
Calculation error
134
4.0
9
11.3
12
1.2
9
1.5
104
6.5
113
3.4
0
0
27
2.6
28
4.7
58
3.6
108
3.3
4
5.0
23
2.2
26
4.4
55
3.4
System safeguard(s)
99
3.0
3
3.8
48
4.6
24
4.0
24
1.5
82
2.5
1
1.3
32
3.1
18
3.0
31
1.9
Workflow disruption
81
2.4
1
1.3
20
1.9
8
1.3
52
3.2
78
2.4
1
1.3
26
2.5
17
2.9
34
2.1
71
2.1
5
6.3
12
1.2
9
1.5
45
2.8
70
2.1
3
3.8
8
0.8
7
1.2
52
3.2
Equipment design
70
2.1
0
0
7
0.7
4
0.7
59
3.7
Verbal order
65
2.0
0
0
18
1.7
15
2.5
32
2.0
55
1.7
2
2.5
27
2.6
14
2.4
12
0.7
45
1.4
1
1.3
17
1.6
13
2.2
14
a
0.9
continued
continued
All Records
Cause of Error
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Brand/generic names look alike
42
1.3
0
0
23
2.2
6
1.0
13
0.8
Fax/scanner involved
41
1.2
0
0
14
1.4
5
0.8
22
1.4
Information management system
38
1.1
2
2.5
17
1.6
4
0.7
15
0.9
Incorrect medication activation
35
1.1
0
0
11
1.1
9
1.5
15
0.9
29
0.9
1
1.3
7
0.7
8
1.3
13
0.8
Patient identification failure
25
0.8
0
0
12
1.2
3
0.5
10
0.6
Brand names look alike
21
0.6
1
1.3
8
0.8
5
0.8
7
0.4
Label (manufacturer’s) design
21
0.6
0
0
8
0.8
6
1.0
7
0.4
Brand/generic names sound alike
20
0.6
0
0
12
1.2
2
0.3
6
0.4
Pump, improper use
19
0.6
0
0
7
0.7
4
0.7
8
0.5
a
Storage proximity
16
0.5
0
0
14
1.4
1
0.2
1
0.1
Nonformulary drug
15
0.5
0
0
2
0.2
1
0.2
12
0.7
Brand names sound alike
14
0.4
1
1.3
5
0.5
3
0.5
5
0.3
Generic names sound alike
14
0.4
0
0
8
0.8
2
0.3
4
0.2
Computer software
13
0.4
0
0
4
0.4
1
0.2
8
0.5
Generic names look alike
13
0.4
0
0
5
0.5
2
0.3
6
0.4
Label (your facility’s) design
12
0.4
0
0
2
0.2
5
0.8
5
0.3
Leading zero missing
12
0.4
0
0
0
0
0
0
12
0.7
Contraindicated in disease
11
0.3
0
0
5
0.5
5
0.8
1
0.1
Reconciliation-transition
11
0.3
0
0
2
0.2
2
0.3
7
0.4
Drug shortage
10
0.3
0
0
1
0.1
0
0
9
0.6
Blanket orders
7
0.2
0
0
2
0.2
1
0.2
4
0.2
Decimal point
7
0.2
1
1.3
1
0.1
1
0.2
4
0.2
Diluent wrong
7
0.2
0
0
2
0.2
3
0.5
2
0.1
Reference material
6
0.2
0
0
2
0.2
1
0.2
3
0.2
a
Pediatric
a
continued
continued
Cause of Error
All Records
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Contraindicated, drug/drug
5
0.2
0
0
2
0.2
2
0.3
1
0.1
Pump, failure/malfunction
5
0.2
0
0
4
0.4
0
0
1
0.1
Measuring device
4
0.1
1
1.3
2
0.2
0
0
1
0.1
Reconciliation-admission
4
0.1
0
0
2
0.2
1
0.2
1
0.1
Trailing/terminal zero
4
0.1
0
0
0
0
0
2.5
4
0.2
Equipment (not pumps) failure/malfunction
3
0.1
0
0
1
0.1
1
0.2
1
0.1
Prefix/suffix misinterpreted
3
0.1
0
1
0.1
0
0
2
0.1
Nonmetric units used
2
0.1
0
0
0
0
0
0
2
0.1
Contraindicated, drug/food
1
<0.1
0
0
0
0
0
0
1
0.1
Repackaging by your facility
1
<0.1
0
0
1
0.1
0
0
0
0
0
6,051
143
1,871
1,086
2,951
Number of Records
3,315
80
1,036
594
1,605
Technical Appendix 5. Causes of Error, by Clinical Unit, by Population (continued)
All Records
Cause of Error
Adult
Geriatric
%
n
%
n
%
n
Performance deficit
499
64.7
16
66.7
139
58.9
79
372
48.2
4
16.7
68
28.8
Documentation
272
35.3
2
8.3
21
8.9
Computer software
220
28.5
0
0
3
1.3
Communication
136
17.6
7
29.2
56
23.7
45
5.8
1
4.2
13
5.5
Knowledge deficit
42
5.4
1
0
18
39
5.1
3
12.5
Written order
31
4.0
3
12.5
29
3.8
1
27
3.5
25
System safeguard(s)
Computer entry
a
Pediatric
n
Workflow disruption
a
%
Age Not Provided
n
%
53
265
73.2
55
36.9
245
67.7
18
12.1
231
63.8
0
0
217
59.9
48
32.2
25
6.9
9
6.0
22
6.1
7.6
14
9.4
9
2.5
13
5.5
12
8.1
11
3.0
9
3.8
9
6.0
10
2.8
4.2
10
4.2
6
4.0
12
3.3
1
4.2
10
4.2
7
4.7
9
2.5
3.2
1
4.2
8
3.4
11
7.4
5
1.4
25
3.2
1
4.2
10
4.2
9
6.0
5
1.4
19
2.5
1
4.2
10
4.2
2
1.3
6
1.7
17
2.2
0
0
5
2.1
5
3.4
7
1.9
15
1.9
1
4.2
12
5.1
2
1.3
0
0
10
1.3
1
4.2
4
1.7
3
2.0
2
0.6
Verbal order
10
1.3
0
0
7
3.0
3
2.0
0
0
8
1.0
0
0
5
2.1
0
0
3
0.8
7
0.9
0
0
1
0.4
6
4.0
0
0
7
0.9
1
4.2
3
1.3
1
0.7
2
0.6
Abbreviations
6
0.8
1
4.2
0
0
1
0.7
4
1.1
Calculation error
6
0.8
0
0
0
0
2
1.3
4
1.1
6
0.8
0
0
4
1.7
1
0.7
1
0.3
continued
continued
All Records
Cause of Error
Pediatric
Adult
Geriatric
Age Not Provided
%
n
%
n
%
n
%
n
%
5
0.6
0
0
3
1.3
2
1.3
0
0
5
0.6
0
0
2
0.8
0
0
3
0.8
5
0.6
0
0
3
1.3
2
1.3
0
0
4
0.5
0
0
3
1.3
1
0.7
0
0
4
0.5
0
0
3
1.3
0
0
1
0.3
Pump, improper use
4
0.5
0
0
1
0.4
3
2.0
0
0
4
0.5
0
0
0
0
3
2.0
1
0.3
3
0.4
0
0
2
0.8
0
0
1
0.3
3
0.4
0
0
1
0.4
1
0.7
1
0.3
3
0.4
0
0
1
0.4
1
0.7
1
0.3
3
0.4
0
0
1
0.4
2
1.3
0
0
2
0.3
0
0
1
0.4
0
0
1
0.3
2
0.3
0
0
2
0.8
0
0
0
0
Diluent wrong
2
0.3
0
0
0
0
2
1.3
0
0
2
0.3
0
0
0
0
0
0
2
0.6
Drug shortage
2
0.3
0
0
0
0
1
0.7
1
0.3
2
0.3
0
0
2
0.8
0
0
0
0
2
0.3
0
0
1
0.4
1
0.7
0
0
2
0.3
0
0
0
0
0
0
2
0.6
Non-formulary drug
2
0.3
0
0
0
0
0
0
2
0.6
Storage proximity
2
0.3
0
0
1
0.4
0
0
1
0.3
Blanket orders
1
0.1
0
0
1
0.4
0
0
0
0
1
0.1
0
0
1
0.4
0
0
0
0
Decimal point
1
0.1
0
0
0
0
1
0.7
0
0
1
0.1
0
0
1
0.4
0
0
0
0
a
a
a
continued
n
continued
All Records
Cause of Error
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
1
0.1
0
0
0
0
0
0
1
0.3
1
0.1
0
0
1
0.4
0
0
0
0
Repackaging by other facility
1
0.1
0
0
0
0
0
0
1
0.3
Weight
1
0.1
0
0
0
0
0
0
1
0.3
Reconciliation-discharge
a
Number of Records
1,944
46
460
323
1,115
771
24
236
149
362
Operating Room
All Records
Cause of Error
Performance deficit
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
1,502
41.8
70
40.9
552
45.4
295
44.5
585
37.8
979
27.2
48
28.1
318
26.2
194
29.3
419
27.1
Communication
650
18.1
42
24.6
281
23.1
145
21.9
182
11.8
Documentation
484
13.5
20
11.7
143
11.8
74
11.2
247
16.0
337
9.4
7
4.1
114
9.4
55
8.3
161
10.4
Knowledge deficit
331
9.2
20
11.7
126
10.4
67
10.1
118
7.6
176
4.9
2
1.2
31
2.5
21
3.2
122
7.9
155
4.3
2
1.2
37
3.0
20
3.0
96
6.2
System safeguard(s)
148
4.1
6
3.5
61
5.0
37
5.6
44
2.8
129
3.6
6
3.5
47
3.9
30
4.5
46
3.0
126
3.5
5
2.9
34
2.8
19
2.9
68
4.4
Written order
104
2.9
3
1.8
29
2.4
16
2.4
56
3.6
Verbal order
102
2.8
10
5.8
41
3.4
17
2.6
34
2.2
93
2.6
5
2.9
34
2.8
23
3.5
31
2.0
87
2.4
7
4.1
32
2.6
18
2.7
30
1.9
80
2.2
0
0
19
1.6
10
1.5
51
3.3
74
2.1
5
2.9
25
2.1
15
2.3
29
1.9
Calculation error
71
2.0
17
9.9
29
2.4
10
1.5
15
1.0
Pump, improper use
61
1.7
11
6.4
29
2.4
11
1.7
10
0.6
Computer entry
55
1.5
2
1.2
10
0.8
11
1.7
32
2.1
47
1.3
1
0.6
21
1.7
9
1.4
16
1.0
44
1.2
0
0
10
0.8
4
0.6
30
1.9
43
1.2
3
1.8
15
1.2
9
1.4
16
1.0
41
1.1
2
1.2
16
1.3
7
1.1
16
1.0
a
continued
continued
All Records
Cause of Error
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
40
1.1
3
1.8
15
1.2
7
1.1
15
1.0
39
1.1
1
0.6
7
0.6
11
1.7
20
1.3
38
1.1
1
0.6
9
0.7
10
1.5
18
1.2
36
1
2
1.2
14
1.2
8
1.2
12
0.8
34
0.9
3
1.8
10
0.8
13
2.0
8
0.5
26
0.7
0
0
11
0.9
5
0.8
10
0.6
25
0.7
2
1.2
9
0.7
8
1.2
6
0.4
Workflow disruption
25
0.7
0
0
6
0.5
7
1.1
12
0.8
Abbreviations
24
0.7
1
0.6
4
0.3
2
0.3
17
1.1
24
0.7
0
0
7
0.6
8
1.2
9
0.6
Diluent wrong
23
0.6
1
0.6
9
0.7
9
1.4
4
0.3
Storage proximity
23
0.6
0
0
10
0.8
4
0.6
9
0.6
21
0.6
1
0.6
9
0.7
4
0.6
7
0.5
Equipment design
20
0.6
1
0.6
6
0.5
4
0.6
9
0.6
Computer software
16
0.4
0
0
6
0.5
2
0.3
8
0.5
14
0.4
1
0.6
4
0.3
3
0.5
6
0.4
Drug shortage
13
0.4
2
1.2
4
0.3
1
0.2
6
0.4
12
0.3
0
0
6
0.5
4
0.6
2
0.1
a
12
0.3
0
0
5
0.4
4
0.6
3
0.2
10
0.3
0
0
7
0.6
1
0.2
2
0.1
Decimal point
10
0.3
1
0.6
2
0.2
1
0.2
6
0.4
8
0.2
0
0
6
0.5
1
0.2
1
0.1
Reference material
8
0.2
0
0
3
0.2
3
0.5
2
0.1
6
0.2
0
0
1
0.1
2
0.3
3
0.2
5
0.1
0
0
2
0.2
2
0.3
1
0.1
5
0.1
0
0
4
0.3
0
0
1
Blanket orders
a
a
0.1
continued
continued
All Records
Cause of Error
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
4
0.1
0
0
1
0.1
0
0
3
0.2
Non-formulary drug
4
0.1
0
0
1
0.1
0
0
3
0.2
4
0.1
0
0
1
0.1
2
0.3
1
0.1
3
0.1
0
0
1
0.1
0
0
2
0.1
a
Measuring device
3
0.1
1
0.6
1
0.1
0
0
1
0.1
3
0.1
0
0
0
0
1
0.2
2
0.1
2
0.1
0
0
2
0.2
0
0
0
0
2
0.1
0
0
0
0
1
0.2
1
0.1
Similar products
2
0.1
0
0
1
0.1
0
0
1
0.1
Non-metric units used
1
< 0.1
0
0
1
0.1
0
0
0
0
1
< 0.1
0
0
1
0.1
0
0
0
0
1
< 0.1
0
0
1
0.1
0
0
0
0
a
6,466
315
2,241
1,245
2,665
Number of Records
3,596
171
1,216
663
1,546
All Records
Cause of Error
n
Performance deficit
1,296
%
Pediatric
n
%
Adult
n
Geriatric
%
n
%
Age Not Provided
n
%
41.4
36
47.4
523
47.5
296
50.3
441
32.3
813
26
23
30.3
319
29.0
177
30.1
294
21.6
Communication
486
15.5
17
22.4
210
19.1
118
20.1
141
10.3
Knowledge deficit
354
11.3
12
15.8
115
10.5
57
9.7
170
12.5
Documentation
338
10.8
5
6.6
123
11.2
62
10.5
148
10.9
194
6.2
1
1.3
93
8.5
44
7.5
56
4.1
Written order
194
6.2
8
10.5
51
4.6
29
4.9
106
7.8
188
6.0
2
2.6
71
6.5
39
6.6
76
5.6
Pump, improper use
155
5.0
1
1.3
93
8.5
47
8.0
14
1.0
152
4.9
2
2.6
45
4.1
29
4.9
76
5.6
148
4.7
2
2.6
63
5.7
34
5.8
49
3.6
140
4.5
1
1.3
31
2.8
21
3.6
87
6.4
Computer entry
116
3.7
1
1.3
20
1.8
14
2.4
81
5.9
System safeguard(s)
113
3.6
1
1.3
43
3.9
38
6.5
31
2.3
Abbreviations
86
2.7
0
0
8
0.7
2
0.3
76
5.6
Calculation error
83
2.7
12
15.8
27
2.5
24
4.1
20
1.5
79
2.5
0
0
18
1.6
10
1.7
51
3.7
76
2.4
1
1.3
26
2.4
11
1.9
38
2.8
Verbal order
76
2.4
3
3.9
24
2.2
13
2.2
36
2.6
51
1.6
3
3.9
14
1.3
8
1.4
26
1.9
Workflow disruption
51
1.6
0
0
8
0.7
1
0.2
42
3.1
50
1.6
0
0
20
1.8
8
1.4
22
1.6
47
1.5
1
1.3
22
2.0
13
2.2
11
0.8
44
1.4
0
0
4
0.4
4
0.7
36
2.6
a
continued
continued
All Records
Cause of Error
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
44
1.4
0
0
13
1.2
3
0.5
28
2.1
39
1.2
2
2.6
6
0.5
5
0.9
26
1.9
39
1.2
0
0
10
0.9
8
1.4
21
1.5
27
0.9
0
0
16
1.5
5
0.9
6
0.4
Equipment design
25
0.8
0
0
12
1.1
4
0.7
9
0.7
23
0.7
0
0
9
0.8
6
1
8
0.6
Blanket orders
22
0.7
0
0
0
0
3
0.5
19
1.4
22
0.7
0
0
6
0.5
3
0.5
13
1.0
22
0.7
0
0
9
0.8
1
0.2
12
0.9
Computer software
21
0.7
0
0
6
0.5
2
0.3
13
1.0
20
0.6
0
0
4
0.4
1
0.2
15
1.1
Decimal point
19
0.6
3
3.9
6
0.5
3
0.5
7
0.5
19
0.6
0
0
7
0.6
6
1.0
6
0.4
18
0.6
1
1.3
6
0.5
5
0.9
6
0.4
17
0.5
0
0
1
0.1
0
0
16
1.2
16
0.5
0
0
4
0.4
1
0.2
11
0.8
15
0.5
0
0
6
0.5
2
0.3
7
0.5
a
15
0.5
0
0
6
0.5
2
0.3
7
0.5
14
0.4
0
0
6
0.5
4
0.7
4
0.3
10
0.3
0
0
2
0.2
2
0.3
6
0.4
10
0.3
0
0
5
0.5
1
0.2
4
0.3
10
0.3
0
0
5
0.5
2
0.3
3
0.2
†
Similar products
9
0.3
0
0
2
0.2
3
0.5
4
0.3
7
0.2
0
0
1
0.1
3
0.5
3
0.2
7
0.2
0
0
1
0.1
1
0.2
5
0.4
continued
Storage proximity
continued
All Records
Cause of Error
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
Drug shortage
6
0.2
0
0
2
0.2
1
0.2
3
0.2
Diluent wrong
5
0.2
0
0
4
0.4
1
0.2
0
0
Nonformulary drug
4
0.1
1
1.3
0
0
0
0
3
0.2
4
0.1
0
0
0
0
0
0
4
0.3
2
0.1
0
0
0
0
0
0
2
0.1
2
0.1
0
0
0
0
1
0.2
1
0.1
Measuring device
2
0.1
0
0
1
0.1
0
0
1
0.1
2
0.1
0
0
0
0
0
0
2
0.1
Reference material
2
0.1
0
0
0
0
2
0.3
0
0
2
0.1
0
0
0
0
1
0.2
1
0.1
1
0
0
0
1
0.1
0
0
0
0
1
0
0
0
0
0
1
0.2
0
0
MAR variance
Override
a
a
Unlabeled syringe/container
a
 Number of Selections
5,853
139
2,128
1,182
2,404
 Number of Records
3,128
76
1,100
588
1,364
Technical Appendix 6. Contributing Factors, by Clinical Unit, by Population
All Records
Contributing Factor
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
None
544
43.1
17
51.5
189
37.1
106
36.3
232
54.3
Distractions
364
28.9
11
33.3
162
31.8
95
32.5
96
22.5
115
9.1
1
3.0
53
10.4
24
8.2
37
8.7
Workload increase
105
8.3
3
9.1
46
9.0
30
10.3
26
6.1
Cross coverage
70
5.6
1
3
32
6.3
15
5.1
22
5.2
41
3.3
0
0
13
2.6
14
4.8
14
3.3
41
3.3
0
0
16
3.1
9
3.1
16
3.7
Patient transfer
a
41
3.3
0
0
22
4.3
12
4.1
7
1.6
Emergency situation
15
1.2
0
0
4
0.8
4
1.4
7
1.6
Shift change
19
1.5
0
0
10
2.0
7
2.4
2
0.5
Staff, floating
17
1.3
0
0
10
2.0
2
0.7
5
1.2
No 24-hour pharmacy
11
0.9
0
0
6
1.2
5
1.7
0
0
13
1.0
1
3
6
1.2
5
1.7
1
0.2
13
1.0
0
0
4
0.8
3
1.0
6
1.4
7
0.6
0
0
4
0.8
3
1.0
0
0
7
0.6
1
3
4
0.8
0
0
2
0.5
4
0.3
0
0
1
0.2
1
0.3
2
0.5
4
0.3
0
0
1
0.2
0
0
3
0.7
Code situation
2
0.2
0
0
1
0.2
0
0
1
0.2
a
1
0.1
0
0
1
0.2
0
0
0
0
a
Poor lighting
Computer system/network down
Range orders
a
1,434
35
585
335
479
Number of Records
1,261
33
509
292
427
Technical Appendix 6. Contributing Factors, by Clinical Unit, by Population (continued)
All Records
Contributing Factor
%
n
199
53.1
4
80
21.3
Patient transfer
28
Cross coverage
Workload increase
Geriatric
Age Not Provided
%
n
%
n
%
40
51
37.8
37
38.5
107
79.9
3
30
38
28.1
25
26.0
14
10.4
7.5
1
10
14
10.4
10
10.4
3
2.2
25
6.7
0
0
13
9.6
10
10.4
2
1.5
24
6.4
2
20
12
8.9
9
9.4
1
0.7
22
5.9
1
10
15
11.1
4
4.2
2
1.5
6
1.6
0
0
3
2.2
2
2.1
1
0.7
Shift change
6
1.6
0
0
4
3.0
2
2.1
0
0
6
1.6
0
0
6
4.4
0
0
0
0
Emergency situation
5
1.3
0
0
1
0.7
1
1.0
3
2.2
4
1.1
0
0
1
0.7
1
1.0
2
1.5
2
0.5
0
0
1
0.7
0
0
1
0.7
Staff floating
2
0.5
0
0
1
0.7
0
0
1
0.7
Code situation
1
0.3
0
0
1
0.7
0
0
0
0
1
0.3
0
0
1
0.7
0
0
0
0
Patient name similar/same
1
0.3
0
0
0
0
1
1.0
0
0
Staffing, agency/temporary
1
0.3
1
10
0
0
0
0
0
0
1
0.3
0
0
0
0
0
0
1
0.7
Distractions
a
No 24-hour pharmacy
a
a
%
Adult
n
None
Pediatric
n
414
12
162
102
138
Number of Records
375
10
135
96
134
Operating Room
All Records
Contributing Factor
Pediatric
Adult
Geriatric
Age not Not
Provided
n
%
n
%
n
%
n
%
n
%
None
488
39.8
24
35.3
204
38.1
105
38.2
155
44.4
Distractions
320
26.1
20
29.4
153
28.6
63
22.9
84
24.1
165
13.4
12
17.6
65
12.1
33
12
55
15.8
Workload increase
88
7.2
0
0
45
8.4
21
7.6
22
6.3
Cross coverage
75
6.1
2
2.9
35
6.5
20
7.3
18
5.2
Emergency situation
52
4.2
2
2.9
21
3.9
12
4.4
17
4.9
42
3.4
1
1.5
18
3.4
12
4.4
11
3.2
a
47
3.8
1
1.5
26
4.9
17
6.2
3
0.9
27
2.2
3
4.4
9
1.7
11
4.0
4
1.1
19
1.5
0
0
5
0.9
5
1.8
9
2.6
23
1.9
1
1.5
11
2.1
7
2.5
4
1.1
No 24-hour pharmacy
12
1.0
1
1.5
6
1.1
1
0.4
4
1.1
Poor lighting
13
1.1
1
1.5
3
0.6
3
1.1
6
1.7
Code situation
11
0.9
0
0
5
0.9
2
0.7
4
1.1
7
0.6
1
1.5
3
0.6
1
0.4
2
0.6
9
0.7
0
0
0
0
0
0
9
2.6
5
0.4
0
0
1
0.2
1
0.4
3
0.9
Staff, floating
7
0.6
2
2.9
3
0.6
1
0.4
1
0.3
15
1.2
1
1.5
5
0.9
5
1.8
4
1.1
a
a
a
Imprint identification failure
1,425
72
618
320
415
Number of Records
1,227
68
535
275
349
Patient transfer
Shift change
Post anesthesia Care Unit
All Records
Contributing Factor
None
Adult
n
%
n
%
n
513
42.3
9
27.3
171
Geriatric
%
35
Age Not Provided
n
%
n
%
86
37.2
247
53.5
Distractions
289
23.8
8
24.2
125
25.6
61
26.4
95
20.6
113
9.3
7
21.2
50
10.2
15
6.5
41
8.9
Workload increase
94
7.7
1
3.0
41
8.4
16
6.9
36
7.8
90
7.4
4
12.1
45
9.2
22
9.5
19
4.1
Patient transfer
a
Cross coverage
75
6.2
0
0
30
6.1
20
8.7
25
5.4
56
4.6
1
3.0
23
4.7
14
6.1
18
3.9
Shift change
39
3.2
2
6.1
20
4.1
11
4.8
6
1.3
Emergency situation
27
2.2
0
0
10
2.0
10
4.3
7
1.5
27
2.2
1
3.0
16
3.3
4
1.7
6
1.3
15
1.2
0
0
7
1.4
6
2.6
2
0.4
Staff, floating
12
1.0
0
0
8
1.6
2
0.9
2
0.4
10
0.8
1
3.0
4
0.8
2
0.9
3
0.6
9
0.7
0
0
5
1.0
1
0.4
3
0.6
No 24-hour pharmacy
a
Pediatric
a
Poor lighting
Code situation
Range orders
a
a
8
0.7
0
0
4
0.8
1
0.4
3
0.6
6
0.5
0
0
2
0.4
1
0.4
3
0.6
3
0.2
1
3.0
0
0
2
0.9
0
0
2
0.2
0
0
0
0
1
0.4
1
0.2
2
0.2
0
0
0
0
0
0
2
0.4
0
0
0
0
0
 
0
0
0
0
1,390
35
561
275
519
Number of Records
1,214
33
488
231
462
Technical Appendix 7. Actions Taken as a Result of the Error, by Clinical Unit, by Population
All Records
Action Taken
Pediatric
n
%
n
906
55.5
30
319
19.6
7
Education/training provided
317
19.4
307
%
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
60
323
52.9
225
60.8
328
54.7
14
125
20.5
76
20.5
111
18.5
9
18
128
20.9
78
21.1
102
17.0
18.8
8
16
129
21.1
82
22.2
88
14.7
200
12.3
8
16
97
15.9
54
14.6
41
6.8
None
127
7.8
4
8
49
8
22
5.9
52
8.7
of medication error
88
5.4
3
6
40
6.5
23
6.2
22
3.7
Policy/procedure changed
32
2.0
0
0
15
2.5
9
2.4
8
1.3
26
1.6
0
0
10
1.6
9
2.4
7
1.2
22
1.3
2
4
11
1.8
2
0.5
7
1.2
17
1.0
0
0
3
0.5
7
1.9
7
1.2
10
0.6
1
2
2
0.3
0
0
7
1.2
Formulary changed
2
0.1
0
0
1
0.2
0
0
1
0.2
2,373
72
933
587
781
Number of Records
1,631
50
611
370
600
Technical Appendix 7. Actions Taken as a Result of the Error, by Clinical Unit, by Population (continued)
All Records
Action Taken
n
%
Pediatric
n
%
Adult
n
Geriatric
%
n
%
Age Not Provided
n
%
371
67.7
8
57.1
91
61.9
48
60
224
73.0
107
19.5
4
28.6
35
23.8
28
35
50
16.3
100
18.2
3
21.4
44
29.9
18
22.5
25
8.1
56
10.2
3
21.4
28
19.0
11
13.8
14
4.6
51
9.3
3
21.4
23
15.6
15
18.8
10
3.3
None
25
4.6
0
0
6
4.1
5
6.3
14
4.6
of medication error
20
3.6
0
0
13
8.8
3
3.8
4
1.3
7
1.3
0
0
3
2.0
1
1.3
3
1.0
5
0.9
0
0
1
0.7
3
3.8
1
0.3
Policy/procedure instituted
4
0.7
0
0
3
2.0
1
1.3
0
0
3
0.5
0
0
3
2.0
0
0
0
0
749
15
250
133
351
Number of Reports
548
8
147
80
313
Operating Room
All Records
Action Taken
Pediatric
Adults
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
940
51.2
23
51.1
348
50.8
217
55.4
352
49.4
361
19.7
7
15.6
145
21.2
93
23.7
116
16.3
380
20.7
11
24.4
150
21.9
69
17.6
150
21.0
349
19
3
6.7
141
20.6
72
18.4
133
18.7
None
253
13.8
11
24.4
92
13.4
53
13.5
97
13.6
183
10
1
2.2
95
13.9
41
10.5
46
6.5
62
1
2.2
29
4.2
15
3.8
17
2.4
3.4
44
2.4
2
4.4
17
2.5
8
2.0
17
2.4
25
1.4
4
8.9
9
1.3
6
1.5
6
0.8
10
0.5
0
0
2
0.3
4
1.0
4
0.6
41
2.2
1
2.2
17
2.5
3
0.8
20
2.8
Formulary changed
6
0.3
1
2.2
2
0.3
1
0.3
2
0.3
of medication error
68
3.7
2
4.4
32
4.7
18
4.6
16
2.2
2,722
67
1,079
600
976
Number of Records
1,835
45
685
392
713
All Records
Action Taken
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
933
55.0
24
70.6
359
57.7
186
57.8
364
50.7
361
21.3
11
32.4
113
18.2
68
21.1
169
23.5
360
21.2
10
29.4
154
24.8
78
24.2
118
16.4
None
218
12.9
2
5.9
89
14.3
43
13.4
84
11.7
211
12.4
8
23.5
87
14.0
35
10.9
81
11.3
207
12.2
3
8.8
97
15.6
41
12.7
66
9.2
of medication error
63
3.7
3
8.8
33
5.3
15
4.7
12
1.7
26
1.5
2
5.9
10
1.6
6
1.9
8
1.1
22
1.3
2
5.9
10
1.6
3
0.9
7
1.0
20
1.2
2
5.9
7
1.1
0
0
11
1.5
13
0.8
1
2.9
5
0.8
4
1.2
3
0.4
9
0.5
0
0
0
0
0
0
9
1.3
Formulary changed
2
0.1
0
0
1
0.2
0
0
1
0.1
2,445
68
965
479
933
Number of Records
1,696
34
622
322
718
Technical Appendix 8. Level of Staff Identified Making the Initial Error, by Clinical Unit, by Population
All Records
Staff
Nurse, Registered
Physician
a
b
Anesthesia provider
c
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
1,799
58.0
62
74.7
806
75.3
461
77.0
470
34.8
827
26.6
9
10.8
120
11.2
66
11.0
632
46.7
94
3.0
6
7.2
21
2
12
2.0
55
4.1
Pharmacist
93
3.0
2
2.4
24
2.2
11
1.8
56
4.1
Nurse, Licensed Practical/Vocational
66
2.1
1
1.2
34
3.2
17
2.8
14
1.0
Pharmacy Technician
47
1.5
0
0
6
0.6
7
1.2
34
2.5
46
1.5
1
1.2
16
1.5
7
1.2
22
1.6
Nursing personnel, nonspecific
d
Unit Secretary/Clerk
45
1.4
1
1.2
14
1.3
6
1.0
24
1.8
Dentist and related specialists
17
0.5
0
0
2
0.2
0
0
15
1.1
15
0.5
0
0
7
0.7
0
0
8
0.6
Patient/family member/caregiver
13
0.4
0
0
7
0.7
4
0.7
2
0.1
Respiratory Therapist
11
0.4
0
0
6
0.6
1
0.2
4
0.3
Physician Assistant
9
0.3
0
0
2
0.2
0
0
7
0.5
Nurse Practitioner/
Advanced Practice Nurse
5
0.2
0
0
2
0.2
0
0
3
0.2
5
0.2
0
0
1
0.1
2
0.3
2
0.1
Pharmacy personnel, nonspecific
Unlicensed assistive personnel
d
d
3
0.1
1
1.2
0
0
1
0.2
1
0.1
3
0.1
0
0
0
0
2
0.3
1
0.1
Optometrist
2
0.1
0
0
0
0
0
0
2
0.1
Laboratory personnel
1
< 0.1
0
0
1
0.1
0
0
0
0
Psych Tech/Mental Health Technician
1
< 0.1
0
0
0
0
1
0.2
0
0
Radiology Technician
1
< 0.1
0
0
1
0.1
0
0
0
0
Staff—not identified
1
< 0.1
0
0
0
0
1
0.2
0
0
3,104
 
83
 
1,070
 
599
 
1,352
 
Number of Records
aIncludes Nurse, Registered; Nurse, Graduate; and Nurse, Travel.
bIncludes Physician; Physician, Resident; Physician, Intern.
cIncludes Anesthesiologists and Certified Registered Nurse Anesthetists.
dSelection not available all years.
Nursing Assistant/Aide
Student
Technical Appendix 8. Level of Staff Identified Making the Initial Error, by Clinical Unit, by Population (continued)
All Records
Staff
a
Nurse, Registered
Physician
b
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
412
67.3
18
75.0
162
67.8
100
66.2
132
66.7
62
10.1
1
4.2
16
6.7
7
4.6
38
19.2
55
9.0
1
4.2
24
10.0
21
13.9
9
4.5
25
4.1
2
8.3
11
4.6
9
6.0
3
1.5
17
2.8
0
0
11
4.6
6
4.0
0
0
Pharmacy Technician
11
1.8
0
0
1
0.4
1
0.7
9
4.5
Pharmacist
9
1.5
0
0
4
1.7
2
1.3
3
1.5
6
1.0
1
4.2
2
0.8
0
0
3
1.5
3
0.5
0
0
1
0.4
2
1.3
0
0
3
0.5
0
0
1
0.4
2
1.3
0
0
Nurse Practitioner/
2
0.3
0
0
1
0.4
0
0
1
0.5
2
0.3
1
4.2
1
0.4
0
0
0
0
Materials Management personnel
1
0.2
0
0
1
0.4
0
0
0
0
1
0.2
0
0
1
0.4
0
0
0
0
Physician Assistant
c
Anesthesia Provider
d
c
Pediatric
1
0.2
0
0
0
0
1
0.7
0
0
c
2
0.3
0
0
2
0.8
0
0
0
0
Number of Records
612
24
239
151
198
cSelection not available all years.
dIncludes Anesthesiologists and Certified Registered Nurse Anesthetists.
Operating Room
All Records
Staff
a
Nurse, Registered
Physician
b
Anesthesia Provider
c
Pharmacist
Pharmacy Technician
d
Pediatric
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
1,434
45.4
72
39.8
646
51.5
364
54.6
352
33.3
758
24
38
21.0
260
20.7
126
18.9
334
31.6
542
17.2
49
27.1
241
19.2
101
15.1
151
14.3
106
3.4
7
3.9
25
2.0
19
2.8
55
5.2
93
2.9
0
0
12
1.0
8
1.2
73
6.9
77
2.4
6
3.3
21
1.7
19
2.8
31
2.9
28
0.9
2
1.1
10
0.8
9
1.3
7
0.7
23
0.7
1
0.6
4
0.3
3
0.4
15
1.4
19
0.6
1
0.6
1
0.1
2
0.3
15
1.4
16
0.5
0
0
10
0.8
3
0.4
3
0.3
13
0.4
2
1.1
3
0.2
3
0.4
5
0.5
d
d
13
0.4
0
0
7
0.6
3
0.4
3
0.3
Student
13
0.4
0
0
4
0.3
4
0.6
5
0.5
Nurse Practitioner/
7
0.2
1
0.6
2
0.2
2
0.3
2
0.2
7
0.2
1
0.6
5
0.4
0
0
1
0.1
4
0.1
0
0
3
0.2
1
0.1
0
0
3
0.1
1
0.6
0
0
0
0
2
0.2
Dentist and related specialties
1
<0.1
0
0
0
0
0
0
1
0.1
Phlebotomist
1
<0.1
0
0
0
0
0
0
1
0.1
Radiology Technician
1
<0.1
0
0
1
0.1
0
0
0
0
Number of Records
3,159
181
1,255
667
1,056
Physician Assistant
All Records
Staff
a
Nurse, Registered
Physician
b
Anesthesia provider
c
Adult
Geriatric
Age Not Provided
n
%
n
%
n
%
n
%
n
%
1,773
59.1
50
64.1
843
74.9
445
73.0
435
36.6
758
25.2
22
28.2
153
13.6
83
13.6
500
42.1
144
4.8
2
2.6
41
3.6
31
5.1
70
5.9
Pharmacy Technician
66
2.2
1
1.3
8
0.7
2
0.3
55
4.6
Pharmacist
65
2.2
1
1.3
21
1.9
8
1.3
35
2.9
60
2.0
0
0
9
0.8
11
1.8
40
3.4
d
52
1.7
1
1.3
20
1.8
10
1.6
21
1.8
24
0.8
0
0
11
1.0
6
1.0
7
0.6
14
0.5
1
1.3
4
0.4
4
0.7
5
0.4
13
0.4
0
0
4
0.4
1
0.2
8
0.7
11
0.4
0
0
3
0.3
1
0.2
7
0.6
5
0.2
0
0
4
0.4
1
0.2
0
0
5
0.2
0
0
1
0.1
3
0.5
1
0.1
4
0.1
0
0
2
0.2
1
0.2
1
0.1
3
0.1
0
0
1
0.1
2
0.3
0
0
Nurse Practitioner/
2
0.1
0
0
0
0
0
0
2
0.2
Student
2
0.1
0
0
1
0.1
0
0
1
0.1
Laboratory personnel
1
<0.1
0
0
0
0
1
0.2
0
0
Physician Assistant
d
Pediatric
d
Number of Records
3,002
78
1,126
610
1,188
Technical Appendix 9: Publications Utilizing MEDMARX Perioperative Data
Beyea SC. Best practices for safe medication administration. AORN Journal
2005;81(3):895, 897-898.
Beyea SC, Hicks RW. Oops—the patient is allergic to that medication. AORN
Journal 2003;77(3):653-654.
Beyea SC, Hicks RW. Patient safety first alert—epinephrine and phenylephrine in surgical settings. AORN Journal 2003;77(4):743-747.
Beyea SC, Hicks RW, Becker SC. Medication errors in day surgery—a secondary analysis of MEDMARX. Surgical Services Manager 2003;9:1.
Beyea SC, Hicks RW, Becker SC. Medication errors in the OR—a secondary
analysis of MEDMARX. AORN Journal 2003;77(1):125-129, 132-134.
Goeckner BL, Gladu M, Bradley J, Bibb SG, Hicks RW. Identifying differences between organizational characteristics and medication errors across
the perioperative continuum using United States Pharmacopeia data. AORN
Journal 2006; 83(2): 351-368
Hicks RW, Becker SC, Krenzischeck D, Beyea SC. Medication errors in post
anesthesia care unit: a secondary analysis of MEDMARX findings. Journal of
Perianesthesia Nursing 2004;19(1):18-28.
Strategies for preventing med errors. OR Manager 2006;22(3):11, 13.
Study of perioperative med errors provides clues for improving care. OR
Manager 2006;22(3):1, 8-9.
Section Title
MEDMARX Technical Appendices (Historical Findings)
Technical Appendix 10. Error Category Index, CY 2001–CY 2005
Technical Appendix 11. Node, CY 2001–CY 2005
Technical Appendix 12. Types of Error, CY 2001–CY 2005
Technical Appendix 13. Cross-Tabulation of Types of Error by Error Severity, CY 2001–CY 2005
Technical Appendix 14. Causes of Error, CY 2000–CY 2005
Technical Appendix 15. Contributing Factors, CY 2001–CY 2005
Technical Appendix 16. Actions Taken as a Result of the Error, CY 2001–CY 2005
Technical Appendix 17. Level of Care Rendered as a Result of the Error, CY 2001–CY 2005
Technical Appendix 18. Leading Products Involved in Medication Errors (All Categories), CY 2005
Technical Appendix 19. Leading Products Involved in Harmful Medication Errors (Categories E–I), CY 2005
Technical Appendix 20. Products and Error Descriptions, Category I Medication Errors, CY 2005
APPENDICES—HISTORICAL
APPENDICES—HISTORICAL << 145
Technical Appendix 10. Error Category Index, CY 2001–CY 2005
CATEGORY
CY 2001
%
CY 2005
n
%
n
10.7
30,111
15.6
37,023
15.7 5.7
35,162
14.1
23,698
10.7
B
36,499
34.6
67,707
35.2
90,296
38.4
105,179
42.3
95,412
43.2
C
47,236
44.7
79,267
41.2
90,012
38.3
90,724
36.5
85,286
38.6
D
8,077
7.6
12,179
6.3
14,271
6.1
14,444
5.8
13,661
6.2
E
2,108
2.0
2,600
1.35
2,845
1.2
2,528
1.02
2,305
1.04
F
384
0.4
514
0.27
574
0.24
569
0.23
523
0.24
G
8
0.01
32
0.02
40
0.02
29
0.01
33
0.01
H
25
0.02
47
0.02
74
0.03
66
0.03
65
0.03
I
14
0.01
20
0.01
24
0.01
32
0.01
17
0.01
105,603
n
CY 2004
11,252
TOTAL
%
CY 2003
A
192,477
2.44
appendices— historical
% Harmful
n
CY 2002
235,159
1.67
%
248,733
1.51
n
%
221,000
1.3
1.33
Technical Appendix 11. Node, CY 2001–CY 2005
CY 2001
NODE
n
b
Procurement
CY 2002
a
%
n/a
n
CY 2003
a
%
n/a
n
CY 2004
a
%
n/a
n
a
%
n/a
CY 2005
n
a
%
322
<1
Prescribing
14,403
15
34,650
21
45,993
23
54,273
26
43,228
22
Transcribing/documenting
24,179
26
37,301
23
45,695
23
44,921
21
41,732
21
Dispensing
19,902
21
35,016
22
43,481
22
50,492
24
51,051
26
Administering
37,378
37
53,612
33
60,788
31
61,373
29
59,018
30
Monitoring
1,125
1
1,758
1
2,179
1
2,062
1
1,962
1
4
<1
29
<1
0
0
0
0
0
0
Data not provided
TOTAL
96,991
162,366
198,136
213,121
197,313
aPercentages have been rounded.
bSelection added during CY 2005.
Technical Appendix 12. Types of Error, CY 2001–CY 2005
CY 2001
Type of Error
CY 2002
a
CY 2003
a
CY 2004
a
n
%
24
54,034
24
52,945
21
51,793
23
22
59,972
24
42,081
19
22,635
10
27,302
11
32,772
15
7
14,116
6
16,923
7
16,511
7
8,704
5
11,4 65
5
14,334
6
13,994
6
5
8,196
5
10,647
5
12,546
5
11,011
5
1,885
2
3,611
2
5,799
3
6,509
3
5,881
3
n/a
n/a
n/a
n/a
n/a
n/a
23
<1
6,127
3
4,275
4
7,204
4
10,591
5
12,291
5
3,540
2
1,315
1
2,372
1
2,669
1
3,790
2
3,599
2
Wrong route
1,743
2
2,738
2
3,273
2
3,649
2
3,451
2
n/a
n/a
26
<1
632
<1
870
<1
809
<1
n/a
n/a
55
<1
288
<1
730
<1
754
<1
n
%
21
44,593
27,714
29
Prescribing error
13,634
n
CY 2005
a
n
%
26
49,100
23
58,861
44,786
26
52,078
24
14
32,416
19
48,954
12,689
13
19,409
11
Wrong time
6,899
7
12,103
Extra dose
6,387
7
Wrong patient
5,054
Wrong dosage form
n
%
20,024
Omission error
Mislabeling
b
Expired product
b
b
%
101,619
186,316
232,247
270,745
246,357
Number of Records
96,779
174,930
218,347
247,250
221,000
103
16,980
Type not determined
c
a
bThese selections were added during CY 2003 or CY 2004.
cThis selection is no longer available in the pick lists.
a
Technical Appendix 13. Cross-Tabulation of Types of Errors, by Error Severity, CY 2001–CY 2005
Non-harmful
Type of Error
Harmful
n
%
n
%
12,952
94.2
798
5.8
Wrong route
14,535
97.9
318
2.1
222,442
98.2
4,159
1.8
Omission error
225,042
98.2
4,202
1.8
112,823
98.3
1,983
1.7
Extra dose
54,035
98.5
846
1.5
37,327
98.5
566
1.5
Wrong time
65,886
99.0
685
1.0
Wrong patient
46,967
99.0
480
1.0
195,271
99.1
1,681
0.9
1,951
99.2
16
0.8
Wrong dosage form
23,525
99.3
164
0.7
2,184
99.3
15
0.7
6,130
99.7
20
0.3
1,021,070
 
15,933
Prescribing error
b
b
Expired product
b
Mislabeling
Total
aBased on 1,037,003 selections associated with 958,053 records.
bSelection not available all five years.
Technical Appendix 14. Causes of Error, CY 2001–CY 2005
CY 2001
Cause of Error
n
a
CY 2003
n
%
a
CY 2004
a
n
%
n
CY 2005
a
%
n
%
Performance deficit
35,690
38
63,954
37
81,024
38
95,542
39
93,618
42
18,981
20
28,857
17
35,937
11
41,295
17
41,069
19
Computer entry
10,353
11
17,998
10
27,711
13
29,483
12
30,898
14
Communication
9,342
10
16,336
9
16,614
8
24,987
10
24,248
11
13,860
15
22,572
13
28,029
13
26,192
11
24,074
11
Knowledge deficit
9,356
10
17,198
10
24,099
11
24,235
10
21,703
10
11,622
12
17,788
10
25,490
12
29,748
12
20,954
10
Documentation
b
n/a
n/a
n/a
n/a
7,029
3
13,647
6
12,325
6
5,363
6
9,522
5
11,223
5
14,130
6
11,981
6
Workflow disruption
n/a
n/a
n/a
n/a
n/a
n/a
9,848
4
11,437
5
Abbreviations
839
1
2,356
1
7,464
4
14,775
6
9,889
4
2,317
2
4,374
3
5,486
3
5,644
2
8,467
4
System safeguard(s)
3,073
3
4,937
3
6,867
3
5,907
2
6,833
3
n/a
n/a
n/a
n/a
7
<1
4,714
2
5,395
2
3,868
4
16,316
9
9,220
4
4,852
2
5,014
2
3,258
3
4,924
3
6,134
3
6,450
3
4,972
2
Calculation error
1,999
2
3,862
2
6,264
3
6,997
3
4,865
2
1,979
2
12,371
7
8,862
4
5,666
2
4,400
2
2,154
2
3,487
2
4,687
2
5,257
2
4,335
2
1,348
1
2,655
2
3,540
2
4,190
2
3,585
2
Verbal order
Written order
b
b
CY 2002
%
1,374
1
3,038
2
3,385
2
3,941
2
3,320
2
869
1
1,527
1
1,790
1
2,423
1
3,236
1
1,409
1
2,775
2
2,869
1
3,183
1
3,189
1
904
1
1,380
1
3,391
2
3,811
2
3,096
1
Computer software
a
continued
Technical Appendix 14. Causes of Error, CY 2001–CY 2005 (continued)
continued
CY 2001
Cause of Error
CY 2002
a
1
2,250
1
2,961
2
3,965
2
4,436
1,860
2
3,003
1,560
a
n
1
951
a
%
%
%
CY 2004
n
n
n
CY 2003
CY 2005
a
%
n
%
1
2,899
1
2
2,837
1
920
1
1,485
1
1,966
1
2,435
1
2,325
1
977
1
1,453
1
1,999
1
2,173
1
2,273
1
Similar products
n/a
n/a
n/a
n/a
n/a
n/a
14
<1
2,254
1
1,176
1
1,997
1
2,636
1
2,719
1
2,179
1
Storage proximity
b
n/a
n/a
5
<1
956
<1
1,907
1
2,157
1
1,227
1
1,733
1
1,835
1
2,032
1
2,099
1
823
1
1,675
1
2,176
1
2,275
1
2,088
1
Pump, improper use
893
1
1,433
1
1,771
1
1,910
1
1,975
1
n/a
n/a
n/a
n/a
n/a
n/a
20
<1
1,920
1
b
MAR variance
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,833
1
496
1
959
1
1,467
1
1,231
1
1,733
1
668
1
1,097
1
1,520
1
1,811
1
1,690
1
944
1
1,755
1
1,894
1
1,700
1
1,407
1
1,093
1
Non-formulary drug
b
b
1
1,756
1
1,719
1
1,406
1
n/a
n/a
n/a
n/a
n/a
26
<1
979
<1
n/a
n/a
3
<1
2,561
1
1,896
1
841
<1
<1
1,092
1
1,496
1
1,062
<1
829
<1
470
785
1
1,029
Decimal point
561
1
835
Blanket orders
n/a
n/a
n/a
560
1
709
1
788
<1
846
<1
707
<1
<1
927
<1
951
<1
643
<1
417
 <1
581
<1
733
<1
580
<1
n/a
<1
n/a
924
n/a
<1
continued
1,537
n/a
a
Technical Appendix 14. Causes of Error, CY 2001–CY 2005 (continued)
continued
CY 2001
Cause of Error
CY 2003
n
a
%
n
CY 2004
a
%
n
CY 2005
a
%
n
a
%
n
%
n/a
 n/a
n/a
 n/a
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a 
1
<1
299
Diluent wrong
253
 n/a
<1
309
<1
397
538
<1
626
<1
379
<1
235
<1
413
<1
415
<1
391
<1
371
<1
132
<1
503
<1
534
<1
504
<1
360
<1
80
<1
128
<1
548
<1
1,073
<1
339
<1
302
<1
b
Equipment (not pumps)
b
b
Drug shortage
Override
b
b
n/a
n/a 
n/a
n/a
n/a
n/a
n/a
n/a
<1
408
<1
453
<1
7
<1
424
<1
<1
393
<1
420
<1
<1
482
<1
382
<1
n/a
n/a
n/a
n/a
140
<1
183
<1
250
<1
279
<1
237
<1
Equipment design
356
<1
469
<1
764
<1
263
<1
231
<1
77
<1
129
<1
261
<1
276
<1
204
<1
73
<1
116
<1
238
<1
445
<1
190
<1
Reference material
80
<1
144
<1
195
<1
183
<1
180
<1
Measuring device
106
<1
137
<1
208
<1
165
<1
109
<1
Weight
b
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
73
<1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
63
<1
n/a
n/a
n/a
n/a
58
<1
72
<1
60
<1
23
84
<1
94
<1
44
<1
17
<1
Contraindicated in pregnancy/
b
breastfeeding
CY 2002
a
b
Unlabeled syringe/container
b
n/a
<1
n/a
34
n/a
<1
n/a
n/a
n/a
n/a
n/a
155,617
284,453
364,799
427,852
405,976
Number of Records
94,498
174,053
212,754
245,922
221,000
Technical Appendix 15. Contributing Factors, CY 2001–CY 2005
CY 2001
Contributing Factor
CY 2002
a
CY 2003
a
n
%
n
Distractions
12,330
47
16,050
43
Workload increase
6,221
24
8,362
22
4,494
17
6,803
18
3,557
14
4,861
13
631
2
929
n/a
n/a
n/a
n/a
Shift change
1,843
n
CY 2004
a
%
CY 2005
a
n
%
n
%
43
26,515
47
24,362
47
9,959
20
15,386
27
13,700
26
8,381
17
8,445
15
9,635
19
4,638
9
4,647
8
4,272
8
3
1,799
4
3,553
6
3,705
7
n/a
n/a
1,690
3
2,331
4
2,524
5
n/a
n/a
8
<1
941
2
2,819
5
7
2,248
6
2,440
5
2,630
5
2,451
5
1,287
5
1,888
5
2,176
4
1,751
3
1,572
3
945
4
1,684
5
1,974
4
1,740
3
1,560
3
No 24-hour pharmacy
753
43
1,414
4
1,214
32
1,649
3
1,576
3
Staff, floating
891
3
1,023
3
1,353
3
1,239
2
1,305
3
520
2
690
2
1,672
3
1,411
3
927
2
n/a
n/a
n/a
n/a
2
<1
1,176
2
1,123
2
Cross coverage
Patient transfer
b
b
Emergency situation
b
b
%
21,333
n/a
n/a
3
<1
718
1
800
1
793
2
396
2
581
2
650
1
620
1
595
1
Code situation
272
1
390
1
503
1
597
1
493
1
b
n/a
n/a
n/a
n/a
n/a
170
<1
264
1
n/a
n/a
n/a
230
1
257
Range orders
b
Fatigue
n/a
Poor lighting
190
n/a
<1
n/a
n/a
1
n/a
284
n/a
<1
316
1
200
<1
34,330
47,156
60,767
75,885
74,192
Number of Records
26,212
37,422
50,101
57,010
52,011
a
Technical Appendix 16. Actions Taken as a Result of the Error, CY 2001–CY 2005
CY 2001
Actions
n
%
CY 2003
a
n
CY 2004
a
%
n
68,665
56
24,136
18
20,053
16
18
19,703
15
18,054
15
16,712
15
17,959
13
13,810
11
7,897
7
17,933
13
20,194
16
66
48,507
65
62,364
55
74,621
Education/Training training provided
7,329
15
14,509
19
19,711
18
8,919
19
13,267
18
20,314
5,508
12
8,642
12
n/a
n/a
n/a
n/a
a
56
31,232
%
CY 2005
%
b
a
n
%
None
6,593
14
8,031
11
13,382
12
16,768
13
15,946
13
of medication error
1,427
3
4,390
6
6,249
6
7,209
5
7,066
6
436
1
760
1
956
1
1,346
1
933
1
506
1
748
1
971
1
1,167
1
1,130
1
382
1
749
1
873
1
843
1
790
1
Policy/ procedure changed
510
1
746
1
1,588
1
842
1
817
1
360
1
488
1
577
1
662
<1
552
<1
76
<1
197
<1
265
<1
194
<1
172
<1
Formulary changed
CY 2002
a
n
63,278
101,034
151,859
183,383
168,182
Number of Records
47,637
74,796
112,607
134,097
122,423
Percent of records
with selections
45
39
48
54
55
bSelection added in CY 2003.
Technical Appendix 17. Level of Care Rendered as a Result of the Error, CY 2001–CY 2005
CY 2001
Level of Care
n
None
b
CY 2002
a
%
n
%
CY 2003
a
CY 2004
a
CY 2005
a
a
n
%
n
%
n
%
20,342
 72
29,560
72
62,240
75
52,104
69
45,477
66
2,913
 10
4,271
10
11,762
14
11,297
15
8,779
13
n/a
3,476
n/a
 12
n/a
4,891
n/a
12
n/a
n/a
3,656
5
6,350
9
6,425
8
6,323
8
5,828
9
1,889
 7
2,700
7
3,342
4
3,139
4
2,889
4
1,656
 6
2,301
6
3,120
4
3,066
4
2,887
4
196
1
297
1
661
1
670
1
570
1
Hospitalization, prolonged 1–5 days
344
1
453
1
502
1
471
1
395
1
137
<1
237
1
306
<1
304
<1
309
<1
Oxygen administered
138
<1
204
<1
270
<1
238
<1
233
<1
103
<1
135
<1
181
<1
187
<1
182
<1
X-ray, CAT, MRI, or other diagnostic
test(s) performed
94
<1
158
<1
168
<1
167
<1
153
<1
79
<1
122
<1
123
<1
120
<1
144
<1
20
<1
36
<1
23
<1
25
<1
Blood product infusion
b
Hospitalization, prolonged 6–10 days
n/a
9
n/a
<1
n/a
23
n/a
<1
n/a
15
n/a
<1
12
<1
19
<1
26
<1
33
<1
23
<1
22
<1
44
<1
33
<1
33
<1
22
<1
55
<1
91
<1
37
<1
30
<1
22
<1
Hospitalization, prolonged more than 10
days
8
<1
19
<1
10
<1
14
<1
12
<1
Cardiac defibrillation performed
9
<1
20
<1
10
<1
12
<1
7
<1
n/a
n/a
<1
15
<1
10
<1
6
<1
31,482
45,545
89,246
81,917
74,349
Number of Records
28,366
40,846
83,224
76,011
68,532
Dialysis
b
Surgery performed
CPR administered
a
Technical Appendix 18. Leading Products Involved in Medication Errors, CY 2001–CY 2005
Generic Name
n
b,c
Insulin
9,135
4.0
5,230
2.3
5,141
2.2
c
4,181
1.8
b,c
Heparin
3,944
1.7
Vancomycin
3,707
1.6
Cefazolin
3,699
1.6
Acetaminophen
3,568
1.6
Warfarin
3,304
1.4
Furosemide
3,178
1.4
Levofloxacin
3,031
1.3
Enoxaparin
2,865
1.3
2,737
1.2
Lorazepam
2,398
1.0
Metoprolol Tartratetartrate
2,326
1.0
2,256
1.0
Ibuprofen
2,165
0.9
Aspirin
2,156
0.9
Piperacillin and Tazobactam
2,095
0.9
b,c
Morphine
b,c
Potassium Chloridechloride
Albuterol
b
Pantoprazole
%
1,918
0.8
Hydromorphone
1,908
0.8
Ceftriaxone
b
1,848
0.8
b
Fentanyl
1,765
0.8
Lisinopril
1,751
0.8
Ipratropium
1,748
0.8
Levothyroxine
1,744
0.8
aData based on 203,690 records with 229,179
selections and 1,514 unique products.
b“High-Alert” medication.
cIncludes all dosage forms.
a
Technical Appendix 19. Leading Products Involved in Harmful Medication Errors (Catagories E-I), CY 2001–CY 2005
Generic Name
b,c
Insulin
b,c
Morphine
b,c
Heparin
n
%
386
11.3
164
4.8
120
3.5
98
2.9
91
2.7
88
2.6
69
2.0
Vancomycin
69
2.0
Enoxaparin
60
1.8
Metoprolol Tartratetartrate
42
1.2
Furosemide
41
1.2
b,c
Fentanyl
b
Hydromorphone
b
Warfarin
b,c
b
Methylprednisolone
35
1.0
Meperidine
33
1.0
Albuterol
32
0.9
Diltiazem
31
0.9
31
0.9
b,c
Levofloxacin
b
Dopamine
0.9
30
0.9
Cefazolin
29
0.8
Lorazepam
29
0.8
Phenytoin
29
0.8
Total Parenteral nNutrition
27
0.8
Midazolam
26
0.8
Metformin
25
0.7
Digoxin
24
0.7
b
b
aData based on 2,918 records with 3,419
selections and 519 unique products.
b“High-Alert” medication.
cIncludes all dosage forms.
30
Nitroglycerin
Technical Appendix 20. Products Involving Patient Deaths (Catagory I) CY 2005
Generic Name
Enoxaparin
A patient with coronary artery stents was being prepared for surgery and per the pre-operative orders, his medications, including enoxaparin, were
placed on hold. The medications were not resumed post-operative, which led to 100% post-operative occlusion in two of the stents. As a result of
the coronary occlusion, the patient expired.
Enoxaparin
A patient with chronic renal failure underwent a cardiac catheterization procedure. During the procedure, the patient was given an excessive dose
of enoxaparin, which resulted in significant blood loss, leading to the patient’s death.
Enoxaparin
An enoxaparin dose was not adjusted for the current renal status of a patient, resulting in an excessive dose. The patient expired.
Enoxaparin
An order to discontinue enoxaparin was overlooked, resulting in the patient receiving additional doses of enoxaparin for five days.
Epinephrine
A critically ill newborn, experiencing significant blood loss, received two 9-fold overdoses of epinephrine during resuscitation.
The concentration expressed on the package (mg) was misinterpreted as the dose (mL), thus resulting in the wrong amount being given.
Flecainide
A pharmacist prepared flecainide suspension correctly, but the label contained inaccurate information.
As a result of the mis-labelling, the infant received five times the prescribed dose.
Flecainide
An infant received an excessive dose of flecainide due to a computer order entry error. The prescriber ordered a dose of 4 mg using the free text
field in the computer system and the pharmacist incorrectly labelled the strength of the solution. As a result of the two errors, the nurse gave a 5fold overdose, which led to a dangerous cardiac arrhythmia.
Gentamicin
A pharmacist dispensed an incorrect amount of gentamicin for an infant. As a result of the wrong dose, the patient died.
Hydromorphone
A physician ordered an incorrect dose of hydromorphone for an elderly patient.
Brand and/or generic name look/sound alike was thought to play a role in the mistake.
Morphine
A dose of oral morphine was administered to a terminally ill patient with liver failure.
The dose was felt to be too high, given the current function of the liver.
Morphine
An elderly post-operative patient received an excessive dose of morphine via a patient- controlled analgesia pump.
As a result of the dose, the patient was unresponsive and eventually experienced a cardiac arrest.
A nurse, who took a verbal order, mistakenly transcribed the wrong amount of potassium chloride
to be added to the total parenteral nutrition solution. As a result, the patient developed hyperkalemia and expired.
continued
Technical Appendix 20. Products Involving Patient Deaths (Catagory I) CY 2005 (continued)
continued
Generic Name
Potassium
Phosphatesphosphates
A (floating) nurse, who was working on a different unit, had an order to give potassium phosphate through a feeding tube. The nurse drew up the
potassium phosphate in a medication syringe because the oral dose syringe did not have adequate markings to confirm the final dose. Two other
staff members interrupted the nurse before the dose was given. Additionally, the nurse stopped to answer the phone. Upon entering the patient’s
room, the nurse gave the medication contained in the syringe through the patient’s intravenous line. The patient expired.
Sodium
Bicarbonatebicarbonate
A patient had an acidotic condition requiring infusion of sodium bicarbonate. There was a four4- hour delay in obtaining the infusion from the
pharmacy, which may have contributed to the patient’s death.
Spironolactone
A physician ordered spironolactone, which was contraindicated for the patient’s diagnosis.
Total Parenteral parenteral
Nutritionnutrition
A total parenteral nutrition solution was ordered to be tapered. There was a communication breakdown and the solution was not tapered.
As a result, the patient developed hypoglycemia, which may have contributed to the patient’s death.
Venlafaxine
A medication had been ordered to be given once daily. The patient complained of dizziness. After consultation with the pharmacy, it was decided
to give the medication at bedtime. However, in preparing the medication administration record, the morning dose was not removed, but the evening dose was added, which resulted in the patient receiving two doses on the same day.
Glossary
Abbreviations—A Cause of error from the MEDMARX pick list. Includes symbols and acronyms.
Communication—A Cause of error from the MEDMARX pick list. Involves
communication that is confusing, intimidating,
Administering—A phase (node) in the medication use process where the drug
product and patient interface. It follows the documenting and/or dispensing nodes and precedes the monitoring node. Administering activities (e.g.,
MAR/patient armband check) may begin in the patient care unit, care delivery
area, or patient bedside and continue through actual drug administration to
the patient. Includes giving the right medication to the right patient at the right
time and informing the patient about the medication.
or lacking between staff, between hospital staff and patient/family, or between
hospital staff and another facility’s staff.
Brand names look alike—A Cause of error from the MEDMARX pick list.
Brand names of different products look similar.
Brand name sounds alike—A Cause of error from the MEDMARX pick list.
Brand names of different products sound similar.
Brand/generic look alike—Cause of error from the MEDMARX pick list.
Brand name/generic names of different products look similar.
Glossary
Calculation error—A Cause of error from the MEDMARX pick list. A miscalculation occurred when trying to determine a mathematical value.
Category Index—A classification system developed by the National
Coordinating Council for Medication Error Reporting and Prevention to group
medication errors by their outcomes into one of nine categories (A–I).
Code situation—A Contributing factor from the MEDMARX pick list. An
emergency situation in which a specialized team of health care professionals are
summoned to the scene by an agreed-upon signal (e.g., code blue) to deliver
immediate life support measures to a patient.
Computer entry—A Cause of error from the MEDMARX pick list. Incorrect
or incomplete information was entered into a computer system associated with
the medication use process.
Computerized prescriber order entry—A Cause of error from the MEDMARX
pick list. A medication error occurs in the prescribing node (phase) of the medication use process due to the incorrect or incomplete entry of a medication
order/prescription into the computer system by a licensed prescriber.
Contraindicated, drug allergy—A Cause of error from the MEDMARX pick
list. A patient is prescribed, dispensed, or administered a medication for which
there is a documented drug/food interaction.
Cross coverage—A Contributing factor from the MEDMARX pick list. A health
care professional who does not have initial/primary responsibility for a patient,
but is temporarily assuming responsibility for a specified time period (e.g.,
lunch break, weekend, holiday) and therefore may have inadequate knowledge
of the patient.
Deteriorated product—A Type of error from the MEDMARX pick list. A product in which the physical or chemical integrity may have been compromised by
improper storage, light exposure, temperature, container type, etc.
Dispensing—A phase (node) in the medication use process that begins with a
pharmacist’s assessment of a medication order and continues to the point of
releasing the product for use by another healthcare professional. Dispensing
activities include order review, entry/processing, preparing, and dispensing
(including stocking automated dispensing devices).
Dispensing device involved—A Cause of error from the MEDMARX pick list.
Includes automated counting and vending systems.
Distractions—A Contributing factor from the MEDMARX pick list. Events that
interfere with or interrupt an individual’s concentrating on the original focus of
attention.
Documentation—A record of pertinent information is inaccurate or lacking.
Dosage form confusion—A Cause of error from the MEDMARX pick list.
Confusion due to similarity in color, shape, and/or size to another product, or
to a different strength of the same product.
Drug distribution system—A Cause of error from the MEDMARX pick list.
Includes stocking (e.g., automated drug dispensing machines), storage, cart filling, and transportation.
Drug prepared incorrectly—A Type of error from the MEDMARX pick list.
Incorrect preparation/formulation of a drug product, (e.g., incorrectly reconstituted or diluted).
Emergency situation—A Contributing factor from the MEDMARX pick list.
A serious situation or occurrence that is unexpected and demands immediate
action.
Expired product—A Type of error from the MEDMARX pick list. A product
with an expiration date beyond the date by which policies and procedures
direct the removal of the product from the stock.
Note: A dose administered after the order was discontinued is considered an
Unauthorized/wrong drug.
Fax/scanner involved—A Cause of error from the MEDMARX pick list. A
faxed version of the medication order is not accurately transmitted (e.g., the
faxed version is too light to read, paper lines may interfere with correct interpretation of the order).
Handwriting illegible/unclear—A Cause of error from the MEDMARX pick
list. Handwriting that is not legible and/or not obvious to the individual who is
trying to interpret the written information.
Harm—Death, or a temporary or permanent impairment of body function/
structure requiring intervention. Intervention may include monitoring the
patient’s condition, change in therapy, or active medical or surgical treatment.
Definition established by the National Coordinating Council for Medication
Error Reporting and Prevention (NCC MERP), 1996.
Imprint identification failure—A Contributing factor from the MEDMARX
pick list. Improper imprinting of patient information on charts or orders resulting in information that is wrong, incomplete, unclear, or missing.
Improper dose/quantity—A Type of error from the MEDMARX pick list.
Involves any dose or strength that differs from the prescribed dose or strength.
Includes incorrect quantity (e.g., tablets, vials) dispensed.
Knowledge deficit—A Cause of error from the MEDMARX pick list. Lack of
understanding; the person did not know better (e.g., a new drug enters the market and the healthcare professional is not aware of its release).
MAR—Medication administration record.
Medication error—Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of
the healthcare professional, patient, or consumer. Such events may be related to
professional practice, healthcare products, procedures, and systems, including
prescribing; order communications; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education;
monitoring; and use.
Source: The National Coordinating Council for Medication Error Reporting and
Prevention (NCC MERP), 1995.
glossary << 161
glossary
Extra dose—A Type of error from the MEDMARX pick list. Involves a duplicate dose administered at a different time.
Gatekeeper—An individual at the local facility who may assign administrative
rights (i.e., access levels to the MEDMARX program) to multiple MEDMARX
users within the facility. Gatekeeper(s) can train facility staff to ensure that
MEDMARX records are accurate, complete, and updated with all necessary
information.
MEDMARX—The Internet-accessible medication error reporting program
operated by the U.S. Pharmacopeia that complements quality improvement
activities at the local and national levels. MEDMARX is available through a
subscription service.
Mislabeling—The drug product was labeled incorrectly.
Monitoring—A phase (node) in the medication use process that involves
evaluating the patient’s physical, emotional, or psychological response to the
medication and recording such findings.
Monitoring inadequate/lacking—A Cause of error from the MEDMARX pick
list. Includes monitoring of blood levels, vital signs, and the like.
Note: If the person was not educated and/or trained the Cause of error should
be classified as Knowledge deficit (chosen from the Cause of error pick list).
Poor lighting—A Contributing factor from the MEDMARX pick list. The lighting where the initial medication error occurred is inadequate.
Preprinted medication order form—A Cause of error from the MEDMARX
pick list. The format, type, size/font, quality, and so on of the medication order
form caused an order to be misinterpreted.
NCC MERP—the National Coordinating Council for Medication Error
Reporting and Prevention.
Prescribing—The phase (node) in the medication use process that involves an
action of a legitimate prescriber to issue a medication order. This phase precedes the documenting node.
No 24-hour pharmacy—A Contributing factor from the MEDMARX pick list.
The institution does not have a pharmacist present 24 hours daily.
Prescribing error—A Type of error from the MEDMARX pick list. Involves an
incorrectly prescribed or authorized order (written or verbal).
No access to patient information—A Contributing factor from the
MEDMARX pick list. Lacking access to pertinent patient information, resulting
in inadequate knowledge of the patient. This information may include medication history, medical diagnosis, medical/surgical history, etc. Note: Failure by
the health care professional to seek or review available patient information is a
Cause of error and should be coded as a Performance deficit (chosen from the
Cause of error pick list).
Procedure/protocol not followed—A Cause of error from the MEDMARX pick
list. Includes established drug regimens, multiple checkpoints, and so on.
Node—A phase in the medication use process (e.g., prescribing, documenting,
dispensing, administering, monitoring).
Glossary
not be explained; the person was educated and/or trained and should have
known better.
list. Involves failure to administer an ordered dose; excludes a patient’s refusal
and a clinical decision (contraindication) or other reason not to administer
(e.g., patient sent to a procedure).
Patient identification failure—A Cause of error from the MEDMARX pick list.
Patient identity was not verified or correctly identified (for example, via wrist
band or medical identification card).
Performance deficit—A Cause of error from the MEDMARX pick list. An
error may not be attributed to any specific cause; the reason for the error can-
Product—The nonproprietary (generic) name of the pharmaceutical agent(s)
reported to be involved in an error.
Range orders—A Contributing factor from the MEDMARX pick list. An order
in which the dose or frequency of a prescribed medication varies in response to
the patient’s clinical situation or condition.
Reconciliation-admission—A Cause of error from the MEDMARX pick list.
The process of identifying an exact list of a patient’s medications, and comparing it against the orders that are made during admission.
Reconciliation-transition—A Cause of error from the MEDMARX pick list.
The process of identifying an exact list of a patient’s medications, and comparing it against the orders that are made during transfer.
Reconciliation-discharge—A Cause of error from the MEDMARX pick list.
The process of identifying an exact list of a patient’s medications, and comparing it against the orders that are made during discharge.
Record—An actual or potential medication error documented in the
MEDMARX database. Records can be stored on hold for updating; or records
can be released to the general database, where they become viewable and
searchable by others.
Shift change—A Contributing factor from the MEDMARX pick list. The time
period when a worker or group of workers relieves another, for example, when
the day shift relieves the night shift.
Similar packaging/labeling—A Cause of error from the MEDMARX pick list.
Example: The packaging/labeling of two or more different products look similar, causing one product to be mistaken for the other.
Staff, agency/temporary—A Contributing factor from the MEDMARX pick
list. A contracted healthcare professional who is not a permanent employee of
the facility.
Staff, floating—A Contributing factor from the MEDMARX pick list. An
employee normally dedicated to one particular area within the facility who is
assigned to temporarily cover another unit or area.
Staff, inexperienced—A Contributing factor from the MEDMARX pick list.
Staff member who has not worked within a particular system or setting, or may
be a novice in a specific area.
Staffing, alternative hours—A Contributing factor from the MEDMARX pick
list. Includes any deviation from normal (e.g., 8-hour) shifts, such as overtime,
double shifts, and 12-hour shifts.
Staffing, insufficient—A Contributing factor from the MEDMARX pick list.
The number and skill level of employees are less than required to safely manage
the amount of work assigned or expected.
Examples: Lack of repetition of verbal orders, double-checking by another person, and computer system alert for maximum dosing.
Transcribing/documenting—A phase (node) in the medication use process
that involves anything related to the act of transcribing an order (by someone
Transcription inaccurate/omitted—A Cause of error from the MEDMARX
pick list. Information is copied incorrectly or not copied at all.
Unauthorized/wrong drug—A Type of error from the MEDMARX pick list.
Medication that was not authorized by a legitimate prescriber is dispensed and/
or administered. Note: Select Wrong patient when ordered for, dispensed for, or
administered to the wrong patient.
Verbal order—A Cause of error from the MEDMARX pick list. Verbal order
was confusing, incomplete, or misunderstood.
Workflow disruption—A Cause of error from the MEDMARX pick list.
Interruption of normal workflow processes through the introduction of barriers to complete performance responsibilities and requirements; may include
unavailability of staff to perform an assigned task due to competing priorities.
Workload increase—A Contributing factor from the MEDMARX pick list. The
amount of work assigned to or expected from an employee in a specified time
period exceeds normal limits.
Written order—A Cause of error from the MEDMARX pick list. Written order
is confusing, incomplete, or misunderstood. Excludes illegible orders.
Wrong administration technique—A Type of error from the MEDMARX pick
list. Inappropriate/improper technique used in the administration of a drug;
includes incorrectly activating a drug administration system and inappropriately crushing tablets.
Wrong dosage form—A Type of error from the MEDMARX pick list. A dosage
form dispensed/administered other than that ordered by the prescriber.
Wrong patient—A Type of error from the MEDMARX pick list. A product
ordered for, dispensed for, or administered to the wrong patient.
Wrong route—A Type of error from the MEDMARX pick list. Use of wrong
route of administration of the correct drug (e.g., intravenous instead of intramuscular).
glossary << 163
glossary
System safeguard(s)—A Cause of error from the MEDMARX pick list. System
safeguard(s) are inadequate or lacking.
other than the prescriber) for order processing (e.g., electronically or manually
in the patient’s record).
Wrong time—A Type of error from the MEDMARX pick list. A scheduled dose
administered outside a facility’s acceptable predetermined time interval.
12.
Pavlac BA. Florence Nightengale. http://departments.kings.edu/womens_history/florence.html.
References
13.
McGarvey HE, Chambers MGA, Boore J, R. P. Development and
definition of the role of the operating department nurse: A review. Journal of
Advanced Nursing. 2000;32(5):1092-1100.
1.
Leape LL. Reporting of adverse events. New England Journal of
Medicine. Nov 14 2002;347(20):1633-1638.
2.
Aspden P, Wolcot J, Bottoman JL, Cronenwett LR, eds. Preventing
Medication Errors. Washington, DC: The National Academies Press; 2006.
3.
Kellier N, Fitzpatrick M, Barach P. Analysis of adverse event reporting
systems and geospatial mapping of Florida AHCA Code 15 data. Miami: Miami
Center for Patient Safety; June 29, 2004 2004.
4.
Rosenthal J, Booth M. Maximizing the use of state adverse event data
to improve patient safety. Portland, ME: National Academy for State Health
Policy; October 2005 2005.
5.
Nyssen AS, Aunac S, Faymonville ME, Lutte I. Reporting systems in
healthcare from a case-by-case experience to a general framework: an example
in anaesthesia. European Journal of Anaesthesiology. Oct 2004;21(10):757-765.
6.
Wachter RM. The end of the beginning: Patient safety five years after
‘To err is human’. Health Affairs. 2004(W4):534-545.
7.
Allen C. Reducing uncertainty. Public Roads. 2004;July/August:35-39.
8.
Frey B, Buettiker V, Hug MI, et al. Does critical incident reporting
contribute to medication error prevention? European Journal of Pediatrics. Nov
2002;161(11):594-599.
Glossary
9.
Haeger K. The illustrated history of surgery. New York: Bell Publishing
Company; 1988.
10.
Meade RH. An introduction to the history of general surgery.
Philadelphia: W. B. Saunders; 1968.
11.
Friedmann P. The history of surgery in Massachusetts. Archives of
Surgery. 2001;136:442-447.
14.
Gabel J, Fitzner K. New evidence to explain rising healthcare costs.
The American Journal of Managed Care. 2003;9(Special Issue 1):SP1-SP2.
15.
National Center for Health Statistics. Ambulatory and inpatient procedures in the United States, 1996: Centers for Disease Control and Prevention;
November 1998.
16.
Nora PF. Improving safety for surgical patients: Suggested strategies.
Bulletin of the American College of Surgeons. 2000;85(9):11-14, 33.
17.
Becher EC, Chassin MR. Improving quality, minimizing error: making it happen. Health Affairs. May-Jun 2001;20(3):68-81.
18.
Schoen C, Osborn R, Huynh PT, et al. Taking the pulse of health care
systems: Experiences of patients with health problems in six countries. Health
Affairs. 2005(5):W509-W525.
glossary
glossary << 165
ISO 9001:2000 Certified
12601 Twinbrook Parkway
Rockville, MD 20852
Email: [email protected]
Phone: 1-301-881-0666
Fax: 1-301-816-8532
www.usp.org/patientsafety

MEDMARX® Data Report

Transcription

Similar documents

Quality Improvement System

Shane Waslaski - Intelligent InSites

TIME TO FILL OUT THAT PAPERWORK change!

LADYWOOD HIGH SCHOOL

MedREady Info Sheet_2016

Presented by Laurie Dupar, Certified ADHD Coach and Nurse

megace pap.ai

NURSING - Harrington HealthCare System

reading cinemas sunbury

Post-Operative Instructions Septoplasty and/or Turbinate Reduction