Public spotlight is on medical errors — don’t become one of the statistics
Public spotlight is on medical errors — don’t become one of the statistics
Take steps to avoid adverse drug events in same-day surgery
We hope your patients don’t watch 20/20. In April, the television news show featured a story on errors that resulted in devastating outcomes for surgical patients. The story discussed specific incidents in which surgical towels and instruments were left inside patients’ bodies. (For tips on how to avoid those types of errors, see story, p. 84.)
In the past year, a significant amount of public attention has focused on medical errors, particularly in surgery. In addition to the 20/20 report, the Joint Commission on Accreditation of Healthcare Organizations issued a sentinel event alert on operative and postoperative complications. (See Same-Day Surgery, May 2000, p. 54.) The Institute of Medicine also issued a report saying out-of-hospital care has "rudimentary" knowledge of the kind and magnitude of errors and the development of safety systems.1
The two most common areas for medical errors are adverse drug events (25% of total medical errors), and surgical incidents (20%), according to Safety-Centered Solutions, a Tampa, FL-based consulting firm focused on error reduction. Researchers estimate medication errors, both in and out of the hospital, account for more than 7,000 deaths annually.2
And outpatient surgery isn’t exempt from medication errors. The Joint Commission has identified "high-alert drugs" that are known to cause severe injury or harm to patients if misused. (For information on how to access the Joint Commission list, see sources and resource box, p. 83.) The Institute also identified similar medications that can cause problems. The Institute’s list includes drugs commonly found in outpatient surgery, including neuromuscular blocking agents, opiates and narcotics, and benzodiazepines.
"Their pharmacology and critical agents, if misused, can result in serious injury in patients," says Marci Kropff, PharmD, fellow at the Institute. For example, narcotics can result in respiratory depression, and neuromuscular agents can relax muscles that control breathing. If these medications have been mistakenly administered to patients who haven’t been properly sedated or put on a mechanical ventilator, "you’ve paralyzed a patient who’s not prepared to be paralyzed," Kropff says.
The fast-paced environment in same-day surgery could be a contributing factor to medication errors, as well as other types of medical errors, some sources say. Officials at the Institute say medication errors can be reduced with electronic prescribing. Some experts predict that electronic prescribing might become required within the next five years to help avoid medication errors.
"I think it’s a good goal for health care in general," Kropff says. "It will help to solve the handwriting problems with handwritten prescriptions."
Many of the electronic prescribing programs use hand-held devices to replace a prescription pad. The provider clicks on medications and instructions.
Problem with state laws
Some states will not allow electronic prescriptions, even if they cut down on medication errors, warns Mark Mayo, facility director at Valley Ambulatory Surgery Center in St. Charles, IL. He is also the consulting editor for Same Day Surgery. The concerns raised by states include secure encryption to avoid access to illegal drugs and narcotics, he says. "Some states don’t allow it because of safety checks on controlled substances. Also, old state laws never considered the possibility of doing prescriptions this way."
Another development intended to reduce medication errors is a self-assessment tool for hospital pharmacies from the Institute. The tool is designed to increase awareness of safe medication systems and help pharmacies improve their systems. Also, the Institute is informing hospitals about how to become part of a confidential national database that will allow benchmarking on safe medication practices.
In the meantime, there are several steps that same-day surgery providers can take to avoid medication errors:
• Store medications appropriately.
Proper storage of drugs means they aren’t available to employees who aren’t familiar with the drugs or their proper use, Kropff emphasizes.
Avoid storing drugs that are easily confused, she advises. She says a staff person at one health care facility confused fentanyl and sufentanil (Sufenta), which is much more potent.
"One of the practitioners thought they were the same thing," Kropff says. Those drugs were stored in a patient care area, where they were accessible to all staff, and there was no double-check system in place, she says.
• Use a double-check system.
The Institute recommends a double-check system for all high-alert medications, Kropff says.
Staff should double check or use a team system when preparing dosages to make sure the right drug and the right quantity are mixed and given to the correct patient, Mayo says. "When they go to calculate the drug, it’s easy to make a decimal point error: 0.1 or 1% makes a big difference."
In a team system approach, you talk your way through the process with another person who’s observing, so it’s correct, Mayo says.
Have a second person verify that you have the proper drug by actually looking at it, Kropff advises. In calculations, have a second person independently perform the calculations in an area away from you and compare results, she suggests.
Develop protocols for certain medications, so there is less of a need to perform calculations, Kropff advises. "Doing calculations is an error-prone process that can result in overdoses and harm to patient," she says.
• Check the patient’s identification.
Staff can overlook patient allergies, Kropff points out. "Look at the ID bracelet to make sure you’re administering the proper drug to the proper patient," she suggests.
Don’t be afraid to ask to see the patient’s ID band before administering any drugs, Mayo says. It’s a good idea to check, even if you "are sure" of who the patient is, he adds. "This might actually reassure some patients that your staff are diligent about avoiding medication errors," Mayo says.
• Provide complete education at discharge.
Take advantage of the discharge process to educate patients about pain medications, Kropff suggests. "Tell them what to expect, and make sure they understand directions and when they should call the doctor," she says.
• Assure staff that they are permitted to question orders.
At Valley Ambulatory, the medical director assures the staff that they have the ability to go to anesthesia personnel and question a drug request by a surgeon, Mayo says. Managers have reiterated that assurance at inservices with nursing staff and nurse anesthetists. "We tell them, yes, it’s OK to do that, and do it before administration" of the drug, he says.
• Tell physicians and patients about steps you’re taking to reduce medical errors.
We’ve talked to patients who start to express some concerns from the TV show [20/20], and we let them know that we take these concerns seriously," Mayo says. Other same-day surgery programs could take that philosophy a step further and post a sign saying, "This center practices error reduction," or "We take steps to minimize medical errors," he adds.
Taking proactive steps to reduce errors makes good sense, he emphasizes. "It protects the patients, and it might be good for business."
(For more information on reducing errors, see Patient Safety Alert, enclosed in this issue.)
References
1. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
2. Phillips DP, Christenfeld N, Glynn LM. Increase in U.S. medication-error deaths between 1983 and 1993. Lancet 1998; 351:643-644.
For more information about medical error prevention, contact:
• Marci Kropff, PharmD, Fellow, Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Telephone: (215) 947-7797. Fax: (215) 914-1492. E-mail: [email protected]. Web site: www.ismp.org.
• Mark Mayo, Facility Director, Valley Ambulatory Surgery Center, 2210 Dean St., St. Charles, IL 61075. Telephone: (630) 584-9801. Fax: (630) 584-9805. E-mail: [email protected].
The Nov. 19, 1999, Sentinel Event Alert, "High-Alert Medications and Patient Safety" can be found on the Web site for the Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org). Or copies can be obtained from the customer service department at no charge. Also, a publication, Medication Use: A Systems Approach to Reducing Errors is available for $60 plus $9.95 for shipping and handling. For more information, contact:
• Joint Commission on Accreditation of Healthcare Organizations, P.O. Box 75751, Chicago, IL 60675-5751. Telephone: (630) 792-5800. Fax: (800) 676-3299 or (302) 678-9200. E-mail: [email protected].
To order a book, Medication Errors, for $70 plus $3 for shipping and handling, or a bimonthly newsletter: ISMP Medication Safety Alert, which costs $135 for one year, contact:
• Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Fax: (215) 914-1492. E-mail: [email protected]. Web site: www.ismp.org.
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