Wrong-Site Surgery Three primary strategies have been identified to reduce the likelihood of wrong-site surgery. 31 Preoperative Verification and Reconciliation. The verification and reconciliation process is typically initiated by the admitting nurse in the preoperative area, but ultimately includes all staff members. The process includes the verification of the procedure to be performed with the patient or patient representative and allows for review of all relevant documents. Any discrepancies are immediately resolved with the attending surgeon. Site Marking. The marking of the surgical site is a preoperative procedure that allows the surgeon to mark the surgical site after a verbal confirmation with the patient or patient representative, and the attending nurse. The site mark acts as a visual confirmation to not only the surgeon, but the entire surgical team. Timeout and Intraoperative Verification. The timeout is the final pause prior to initiating a surgical procedure and should include all staff participating in the procedure. Intraoperatively, a verification process should be utilized to ensure accuracy (site and side) for the consented procedure. Partnership for Patients Core Safety Measures Studies show the potential risk of some errors is far greater than others, with some likely to happen repeatedly. A Partnership for Patients study described the most common medical errors in the United States. Nine core patient safety areas of focus were identified: 32 Adverse Drug Events (Medication Errors); Catheter Associated Urinary Tract Infections (CAUTIs); Central Line- Associated Bloodstream Infections; Injuries from Falls and Immobility; Obstetrical Adverse Effects; Pressure Ulcers; Surgical Site Infections; Venous Thromboembolism; Ventilator-Associated Events. The following are strategies might be used to enhance safety and decrease the occurrence of some of these core safety issues. Adverse Drug Events/Medication Errors: A medication error is an error, of commission or omission, at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. An adverse drug event is defined as harm experienced by a patient as a result of exposure to a medication. The occurrence of an adverse drug event does not necessarily indicate an error or poor-quality care. It is estimated that approximately 50% of adverse drug events are preventable. 33 In some cases, an adverse drug event is an unseen consequence of a medication reaction with therapeutic intent. The incidence of medication errors is an issue of contention. Because definitions of medication errors can differ, many medication errors must be self-reported to be recorded, and data suggest a significant percentage of medication errors are not reported. 19 In addition, there is no central agency or institution responsible for collecting reports of medication errors, so no one knows how many medication errors actually occur.
A medication error is defined as “any preventable event that my cause or lead to inappropriate medication use or patient harm while the mediation is in the control of the healthcare professional, patient, or consumer.” 19 Medication errors are the most common type of medical error. About 1.3 million people are injured annually in the United States following such errors. 34 The incidence of medication errors varies according to patient population and clinical setting. Children and the elderly are more likely to be harmed by medication errors than other segments of the population; children are more susceptible to harm from dosing errors due to their small size, while older individuals tend to take more medications, increasing their potential for medical error and adverse drug interactions. Polypharmacy is not uncommon is patients older than 62 years. 35 Medication errors are more likely to occur in fast- paced, stressful environments such as intensive care units, where errors are more likely to be more severe and cause harm. 36 Data from the FDA show that the most common error involving medications was related to the administration of an improper dose of medicine, accounting for 41% of fatal medication errors. Administering the wrong drug and using the wrong route of administration each accounted for 16% of the errors. 34 Some drugs that are frequent causes of medication errors are commonly used (e.g., insulin and antibiotics). Others are sufficiently potent and there is little room for therapeutic error and substantial potential for harm from seemingly small mistakes (e.g., the cardiovascular drug nitroprusside, heparin, warfarin, insulin, or colchicine). Another set of drugs are common causes of medication errors because they can be easily confused (e.g., Percocet ® [acetaminophen and oxycodone] confused with Vicodin ® [acetaminophen and hydrocodone]). The Institute of for Safe Medication Practices (ISMP) identified some specific medications classified as high-risk, meaning that they are associated with a heightened risk of causing significant patient harm when used inappropriately: 37 • Ephinephrine subcutaneous. • Epoprostenol (Flolan) IV. • Insulin U-500 (All forms of insulin are considered high-risk. Insulin U-500 has been singled out for special emphasis to bring attention to the need for distinct strategies to prevent the types of errors that occur with this concentrated form of insulin). • Magnesium sulfate injection. • Methotrexate, oral, nononcologic use. • Opium tincture. • Oxytocin, IV. • Nitroprusside sodium for injection. • Potassium chloride for injection concentrate. • Potassium phosphates injection. • Promethazine, IV. • Vasopressin, IV or intraosseous.
In an effort to identify root causes, a great deal of attention focused on why medication errors occur. Among a variety of reasons or these mistakes are poor staffing, unskilled/new nurses, stress, personal error, and distraction. These data suggest the most common medication errors are related to an improper dose of medication, administering the wrong dose of medication or the wrong drug, or administering medication via the wrong route. 34 The FDA has also commented on common causes of medication errors as follows: poor communication; ambiguities in product names, directions for use, medical abbreviations, or writing; poor procedures or techniques; patient misuse because of poor understanding of the directions for use of the product; job stress; lack of knowledge or training; similar labeling or packaging. 38 The following list describes the most common causes of medication errors according to specific definitions: 37 • An action-based medication error is defined as the performance of an unintended. Examples of action-based medication errors would include selecting the wrong medication or administering an incorrect dose. • A rule-based medication error occurs because the provider did not follow proper rules or procedures for medication administration. • A memory-based medication error occurs
when a provider forgets to perform a task or forgets important information about the patient. The provider may forget to give a dose of a medication, that the medication has been discontinued, or that the patient is allergic to the medication. Knowledge-based medication errors are errors that could be avoided with a reasonable and appropriate level of professional knowledge. If the provider is familiar with the drug and the patient, knowledge-based medication errors are avoidable. Knowledge-based medication errors can be general, specific, or expert : 37 °
•
A general knowledge-based error occurs when someone makes an error because of lack of or disregard for information that is considered general knowledge (e.g., warfarin can cause bleeding). A specific knowledge-based error occurs when someone makes an error because of lack of or disregard of information that would be considered specific knowledge (e.g., a patient is given warfarin even though the INR is high). expert knowledge-based error occurs when someone makes an error because of lack of, or disregard, for information that would be considered expert knowledge (e.g., the failure to use genetic testing to check for variations in patient response prior to initiating therapy with warfarin). An
°
°
36
Powered by FlippingBook