Medication Errors In Perioperative Settings

A recent report by the Pennsylvania Patient Safety Authority discussed the problems associated with medication errors in the perioperative setting. A perioperative setting is defined as being the period around the time of a surgical procedure. Many of these critical errors stem from negligence and can result in claims of medical malpractice. This unique environment poses certain challenges because standard safety protocol tends to be overlooked. In 2017, there were an estimated 1,137 such errors statewide. Roughly 74% of reported errors involved failures in communication that occur in periods of transition.

Economic Impact

Preventable medication-related errors are estimated to cost a hospital over $600,000 per year—often millions of dollars. The perioperative environment tends to be hectic and stressful. Patients are generally in a transitional stage within the medical continuum. Patients may have exposure to various types of medical staff from various disciplines. When the responsibility for a patient’s care is transferred between providers they are “handed off”. This is when errors are most likely to occur.

Errors During Patient “Handoffs”

Transitions of patient responsibility (handoffs) include preparing, the physical movement of patient location and the transfer of information from one party to another. In a properly executed handoff, the provider that is assuming responsibility receives all the relevant knowledge and information. The primary reasons that these mistakes occur relate to incomplete documentation, sudden interruptions and being distracted.

Patient Identifiers & Unlabeled Containers

The 2017 guidelines by the Joint Commission stressed usage of a minimum of two “patient identifiers” in the administration of medications, sample collection, and other tasks. The physical location or room number of the individual should not be an identifier. No medication, specimen or solution should ever be placed into an unlabeled container. This is a fundamental key in medication management and can be particularly dangerous in the perioperative setting.

Data: Medication-Related Errors

• Roughly 69% of medication errors occurred in an acute care (hospital) setting
• Approximately 28% occurred in children’s hospitals and merely 3% in ambulatory surgical sites
• About 73% of reported errors occurred in the operating room or involved anesthesia
• About 27% of reported errors occurred after the procedure
• “Good catches”, where potential errors are fortunate to be recognized occurred in nearly 37% of the mistakes

Classes of Medications Involved

Analgesics and antibiotics are the classes that were most often associated with these errors. Analgesic products are those generally used for pain relief and antibiotics are used to kill bacteria and prevent infection. Over 50% of the analgesic medications associated with errors are considered to be “high-alert” medications. These include opioids, nerve blockers, and epidurals that are injected to numb an area.

Types of Errors

Approximately 36% of these errors were related to the process of ordering a medication. These may include prescription errors or data entry mistakes into an ordering system or electronic health records system. In many of these cases, the daily frequency of the product was wrong. Many other mistakes related to doses of the medication that was too low or too high. One often tragic error is when a patient receives a medication that they are allergic to.