Risk of Medication Errors Increases for Surgical Patients
The United States Pharmacopeia (USP) released a report (pdf) on March 6th indicating that patients who undergo surgery are at higher risk for medication errors, particularly during the perioperative period. Increased risk is attributed to a distended system, where patients move through different departments following a procedure. This system entails a changing stream of caregivers as patients are transferred, increasing the opportunity for missed information.
MEDMARX, an Internet-based program operated by USP, allows anonymous reporting of medication errors nationwide. Over 11,000 medication errors were documented in the perioperative setting. Five percent had associated morbidity and four cases resulted in patient death. Compared to the overall rate of medication errors tracked by MEDMARX, the risk of harm is threefold during the perioperative period. Antibiotics and pain killers were most frequently involved in errors, particularly dosing and medication administration.
Recommendations from the report include dedicating pharmacists to perioperative departments to oversee medication management. Improved coordination between healthcare providers in different departments, particularly as patients are transferred, is another suggestion. USP also encourages that patients and family members be pro-active communicating with the medical team both before and throughout hospitalization.
Partners in the report include the Uniformed Services University of the Health Sciences (USUHS) (pdf), the Association of periOperative Registered Nurses (AORN), and the American Society of Perianesthesia Nurses (ASPAN).
The MEDMARX data report considered data over an eight year period. The program started in 1998 and over 1.2 million errors have been reported, including more than 870 different healthcare facilities.
March 6, 2007 Related topics: General Management & Administration, Quality, Safety, Errors, Surgery, Policies & Procedures