By Cyndi Newman, MSHL, BSN, RN
Mistakes happen. Even with the best-laid plans, medication administration errors can (and do) occur in pre-, intra- and post-operative settings.
Why?
On a hospital medical floor, medication is managed by multiple staff members, with a series of double-checks before the drug reaches the patient. By contrast, within the OR the anesthesia professional acts as an individual. One person selects, prepares, and administers the medication to the patient2. An ASC setting has its own demands, because staff members often function in multiple roles. A single ASC staff member may administer moderate sedation, but also oversee QAPI, infection control, and any number of other tasks.
Accreditation standards limit potential pitfalls
Safe medication administration in the operating room is fundamental to both patient safety and your organization’s risk management. Compliance with accreditation standards strengthens your policies and helps you develop processes for safe medication practices in the following areas:
- Administration of drugs.
- Labeling, storage and disposal of medications.
- Infection control measures related to medication administration.
- Tracking and trending occurrence of errors.
Anesthesia errors due to incorrect dose
Nearly 30% of anesthesia errors in the OR are due to incorrect dose. Possible contributing factors include distraction, poor communication, and look-alike/sound-alike medications – to name a few1. You can avoid this outcome bHoy ensuring that drugs are both prepared and administered according to established policies, acceptable standards of practice, and accepted professional practice.
At a minimum, medication administration policies must address basic safe practices, including:
- The “five rights” (verification of patient, medication, dose, route, and time). Some organizations expand this to seven, adding the right reason and the right documentation.
- The five stages of the medication process (ordering/prescribing, transcribing and verifying, dispensing and delivering, administering, and monitoring/reporting).
- Medication reconciliation (initial, transfer, discharge).
- “Time-out” to confirm patient identity, site and procedure.
“Acceptable standards of practice” means that drugs are managed and administered in accordance with applicable laws, as well as with standards established by organizations with nationally recognized expertise in the clinical use of drugs.
“Accepted professional practice” requires qualified health care professionals to order and supervise the administration of drugs and biologicals. Verbal orders for drugs and biologicals must be followed by written orders and signed by the prescriber.
Surprisingly frequent deficiencies
According to data collected by ACHC in 2022-23, the most frequently cited survey deficiencies in the ASC include labeling inadequacies, the presence of expired drugs, and breaches in storage security.
Take a look at some examples of common ACHC survey findings:
Date and time of preparation were missing from the pre-operative antibiotic label. In the recovery area, a syringe with a pre-printed fentanyl label lacked documentation of the date, time drawn, and initials of person who drew up the medication.
The locked narcotic cabinet at the nurses’ station contained outdated hydrocodone elixirs.
The anesthesia cart in the OR was found unlocked with no provider in the room. It contained fentanyl, midazolam and diprivan.
Your policies and procedures must address the preparation, storage, and handling of drugs and biologicals. At a minimum, you must:
- Follow the manufacturer’s instructions for storing drugs and biologicals. Include the location(s) of storage areas, medication carts, and dispensing machines.
- Dispose of expired and unused medications in a timely manner.
- Correctly label medications drawn from a vial into a syringe. Pre-filled syringes must be dated, timed, labeled as to both content and expiration date, and initialed by the person who prepared it. Many facilities order labels with blank fields that include the required information.
Efficiency doesn’t prevent infection
Efficiency is important to any organization’s success. However, in the OR, time-saving practices should be carefully examined. For example, while it may appear efficient to pre-draw all medications that will be used for surgeries scheduled the following day, this practice may promote loss of integrity, stability, or security of the medication. Use single-dose vials of medication for only one patient or determine a non-patient care area to access these medications. When using injectable medications, always use aseptic technique.
Create policies that support infection prevention practices, and you’ll maintain a healthy balance between increased productivity and safety.
Protect your patients as well as your organization
Use data to understand the why and where of medication errors. Errors of any type are ripe for consideration as QAPI projects. By tracking and trending against internal and external benchmarks, you identify opportunities for improving quality and reducing risk of patient harm as well as drug diversion. Quality and risk management go hand in hand.
Need an action plan? Here’s how to start:
1. Get familiar with local, state, and federal regulations on medication administration.
2. Develop medication handling and administration policies and procedures based on nationally recognized guidelines, including:
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- Clear identification and separation of look-alike/sound-alike medications.
- A clearly written and well understood time-out policy.
- Expired/unused medications removed and disposed of properly.
- A thorough medication reconciliation that:
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- Identifies what your patient is taking pre-operatively.
- Provides clear post-discharge medication instructions.
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3. Educate staff on the policies.
– Cyndi Newman, MSHL, BSN, RN, is a Senior Clinical Review Specialist and surveyor for ambulatory surgery and office-based surgery centers.
Resources:
- Kim JY, Moore MR, Culwick MD, Hannam JA, Webster CS, Merry AF. Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS. Anaesthesia and Intensive Care. 2022;50(3):204-219. doi:10.1177/0310057X211027578
- Stipp, Melanie M. DNP, MSN, CRNAa,c,d,*; Deng, Hao MD, MPH, DrPH(c)a,b,c; Kong, Kathy MPHa,c; Moore, Sonya DNP, CRNAd; Hickman, Ron L. Jr. PhD, ACNP-BC, FNAP, FAANd; Nanji, Karen C. MD, MPHa,b,c. Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events. Medicine 101(44):p e31432, November 04, 2022. | https://pubmed.ncbi.nlm.nih.gov/36343025/
