Surgical Units Have High Potential for Harmful Medication Errors, USP Says

Cheryl A. Thompson

Medication use in hospital surgical suites and related patient care areas lacks comprehensive oversight, increasing the chance of harmful errors, the United States Pharmacopeia (USP) announced in releasing its newest report on patient safety.

One solution to this problem, USP said, is for hospitals and health systems to dedicate pharmacists to overseeing the distribution of medications in perioperative units.

Another solution presented by USP is for the various surgical staff members to better coordinate handoffs of information.

According to the 168-page MEDMARX Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998–2005, released to the public in early March, 7.2% of the 3,773 operating room (OR) errors reported voluntarily and anonymously to the database since its inception resulted in harm to patients.

The seven-year rate of harmful errors in the other perioperative units—outpatient surgery departments, preoperative holding areas, and postanesthesia care units—was at least 2.9% but less than the rate for ORs (see table).

Medication Errors in Perioperative Unitsa
Perioperative Unit No. Errors % Errors in Unit Resulting in Harm No. Facilities Reporting Errors in Unit
Outpatient surgery department 3427 2.9 422
Preoperative holding areab 779 2.8 177
Operating room 3773 7.2 447
Postanesthesia care unit 3260 5.6 397
aFrom Hicks RW, Becker SC, Cousins DD. 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.
bThis perioperative unit did not exist in the database's list of locations until 2003.

By comparison, 1.3% of the 221,000 medication errors reported to the database in 2005 resulted in patient harm, the USP report said. The report released in early 2006, covering the years 2000–04, put the overall rate of harmful errors at 1.7%.

Roughly half the errors reported for each of the four perioperative units in 1998–2005 occurred during drug- administration activities.

Cefazolin was the drug most commonly reported, 14.7–22.0% of the time regardless of whether any harm resulted, for the errors that occurred in outpatient surgery departments, preoperative holding areas, and ORs. In postanesthesia care units, morphine topped the list at 17.6%.

As for harmful errors, cefazolin was number one in ORs. Morphine, meperidine, or fentanyl was involved in the greatest percentage of harmful errors in the other perioperative units.

The rate of harmful errors for pediatric patients exceeded the rates for adults and geriatric patients during surgery and afterward. In postanesthesia care units, 20.3% of the errors with children involved some level of harm, usually temporary harm that required intervention.

About 44% of the error reports concerning ORs and postanesthesia care units, however, did not state the patient's age.

"It's likely," said Kasey K. Thompson, director of the ASHP Center on Patient Safety, "that problems associated with medication errors in the perioperative setting are sort of uncharted territory in many hospitals. They're sort of an out-of-sight, out-of-mind phenomenon that happens in settings that aren't in the direct observational view of the organization."

He said health care organizations should view the findings in the USP report "as clues to potentially underlying problems with the medication-use process" in perioperative units.

For some organizations, Thompson said, the solution to those problems may be to hire pharmacists for the perioperative setting. Other organizations may decide that they can improve the situation by developing protocols and regularly assessing the medication-use process, he said.

Eric Chernin, clinical pharmacist for the OR pharmacy at Sarasota Memorial Hospital in Florida and a 16-year specialist, said that the USP report, which had 49 tables of data, did not reveal any real surprises to him.

Neither did the report describe the errors in such a way that Chernin said he learned lessons from the experiences of other hospitals.

Sarasota Memorial submits error reports to Medmarx, but Chernin said he personally has not.

Cefazolin probably accounts for about 95% of the antimicrobials administered in perioperative units, Chernin said. In his view, cefazolin's status as the drug most commonly mentioned in the error reports could simply be a consequence of the antimicrobial "being the most common drug." The errors, he said, could be issues of allergy, timing, or pediatric doses.

The finding that children suffered proportionately more of the harmful errors in perioperative units than did adults or geriatric patients came as no surprise to Chernin.

"None of the anesthetic drugs come in dilutions or doses that may be more appropriate for kids," he said of the medications administered in perioperative units. "Everything is adult sized. So I think the possibility for error certainly exists there because of that."

Sarasota Memorial is fortunate, Chernin added, in that some of its anesthesiologists and certified nurse anesthetists had previously worked at hospitals that performed a lot of pediatric surgeries.

Chernin said readers of the USP report need to keep in mind that in the OR itself, where most of the perioperative drug administration occurs, there are no medication orders for pharmacists to review. Rather, there is the anesthesia record on which the anesthesia care team documents the medications it administered, and there is the perioperative record on which the surgical nurse documents the medications that the surgeon administered on the surgical field.

"Occasionally something happens, and nobody knows the patient got the drug," Chernin said, because people almost exclusively examine only the anesthesia record to find whether a medication was given in the OR.

"Most ORs are basically black holes when it comes to drugs," he said. "The central pharmacy sends drugs there, and they never know what happens with them" because of the lack of medication orders.

Of the various recommendations that USP made for decreasing perioperative medication errors, Chernin said the easiest one for pharmacy departments to address pertains to antimicrobial surgical prophylaxis.

Develop strategies, he said in paraphrasing USP, to ensure the appropriate administration of prophylactic antimicrobials. The Joint Commission already wants to know that hospitals have a monitoring program, he explained. And the Surgical Care Improvement Project, which includes measures indicative of appropriate antimicrobial administration, will eventually affect Medicare's payments to hospitals.

"Having an operating room pharmacy satellite," Chernin said while admitting some bias, "is enormously helpful" for ensuring appropriate medication use.

"What I end up doing a lot of is trying to change practice before it happens," he said.

Chernin said most pharmacists, himself included, receive little or no training in the use of drugs in the perioperative setting until they have to work there.

Yet the OR, he said, "is probably the most drug-intensive place in the hospital as far as the number of drugs that are given in such a short period of time."

Analysis and evaluation of the Medmarx data were performed by USP and the Uniformed Services University of the Health Sciences Graduate School of Nursing.

Gerald K. McEvoy, ASHP assistant vice president of drug information, was acknowledged in the report for providing substantial review before its publication.