Perioperative patients face an increased risk of harmful medication errors throughout the surgery process due to a lack of comprehensive oversight of medications, according to the 7th annual national MEDMARX® Data Report released today. The report studied medication errors in the perioperative setting – including outpatient surgery, the preoperative holding area, the operating room and the post anesthesia care unit.
As the largest known national analyses of perioperative medication errors, the MEDMARX report examined more than 11,000 medication errors in the perioperative setting and revealed that 5% of the errors resulted in harm, including four deaths. This percentage of harm is more than three times higher than the percentage of harm among all MEDMARX records. Children are at higher risk for harm in the perioperative setting with nearly 12% of pediatric medication errors resulting in harm.
The report was released by the United States Pharmacopeia (USP) in partnership with the Uniformed Services University of the Health Sciences (USUHS), the Association of Peri -Operative Registered Nurses (AORN) and the American Society of Perianesthesia Nurses (ASPAN). The report coincides with National Patient Safety Awareness Week, March 4-10.
What many people generically call “surgery” is actually a system of several different departments that patients must be transported through to receive perioperative care and each department is likely to have different teams of healthcare providers.
Even if located along a single hallway, these departments can be remarkably disconnected from one another,” says Diane Cousins, R. Ph., vice president of USP’s Healthcare Quality Information department and one of the authors of the report. “The fragmented system creates a high risk for harmful medication errors.”
To improve patient safety and reduce the risk of medication errors, USP recommends that hospitals and health systems dedicate pharmacists to the perioperative units so they can oversee the distribution of medications and thatsurgicalstaff better coordinate hand-offs to eliminate the loss of patient information.
“The MEDMARX report on medication errors in the perioperative setting demonstrates how organizations working together can produce valuable research with concrete recommendations that the healthcare community can use to improve patient safety,” said Peter Pronovost. M.D., Ph.D., medical director, Center for Innovations in Quality Patient Care, The Johns Hopkins University School of Medicine.
The MEDMARX® Data Report A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005 analyzed records from 1998 to 2005 involving pediatric, adult and geriatric patients. Most of the errors in the report involved antibiotics and pain killers. Common types of errors included healthcare providers giving the wrong medication, giving the wrong amount of medicine or giving medication at the wrong time, forgetting to administer medication, or administering it incorrectly.
MEDMARX, operated by USP, is an anonymous, Internet-accessible program used by hospitals and related institutions nationwide to report, track, and analyze medication errors. Since its inception in 1998, MEDMARX has received more than 1.2 million reports of medication errors from more than 870 healthcare facilities across the U.S. It is the largest nongovernmental, Internet-accessible database of medication errors in the U.S.