Dangerous medication errors are most likely to occur in surgical settings, according to a pharmaceutical watchdog.
The United States Pharmacopeia (USP) Center for the Advancement of Patient Safety looked at more than 11,000 mistakes reported be-tween 1998 and 2005 along the “perioperative continuum”: outpatient surgery, preoperative inpatient holding areas, operating rooms, and postanesthesia recovery areas.
It found that 5% of surgery-related errors resulted in harm—including four deaths—and that rate was more than three times higher than the rate of harm from mistakes overall.
Children were particularly vulnerable: Almost 12% of pediatric errors caused harm.
Most of the mistakes involved giving the wrong antibiotics or pain-killers, a wrong dosage, wrong administration, or forgetting to give the drug altogether. Dosage errors were especially apparent in pediatrics, involving 32.4% of incidents reported.
Diane Cousins, RPh, one of the authors of the report, blamed many of the errors on poor communication and coordination as patients move from one department to another. “Even if located along a single hallway, these departments can be remarkably disconnected from one another,” she said. “The fragmented system creates a high risk for harmful medication errors.”
The study, The MEDMARX Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005, recommends:
- Hospitals assign pharmacists to follow each patient through the entire surgical system.
- Manufacturers provide—and hospitals buy—prepackaged single doses of medications whenever possible.
- Satellite pharmacy support be expanded so that medicines are prepared in the area where they will be given.
- The standardization of dose charts and/or technical assistance for calculations to eliminate the risk of wrong dosage.
- Formation of a multidisciplinary team to periodically examine preference cards with physician requirements for particular procedures to ensure clarity of medications intended for the operation and to affirm instruments and equipment needed.
- Longer “time-out” standards to allow sufficient review of the preference card and confirmation of medication directions, patient allergies, and preprocedural antibiotics.
USP, an independent nonprofit agency in Rockville, Md., sets standards for the pharmaceutical industry and maintains the MEDMARX database. It has received more than 1.2 million reports of medication errors from 870 facilities since 1998.
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