Editor's note: This article focuses...

Editor's note: This article focuses onward medication errors in the OR. An article about medication errors that offer in the day surgery setting will appear in the February 2003 issue of SSM one as well as the other articles are based on information derived from the US Pharmacopeia's Medmarx database.

Medication errors have springed in patient deaths and a multitude of serious complications. Errors related to the medication use proces (ie, prescribing, documenting, dispensing, administering, monitoring) are perhaps the in the greatest degree frequent errors that occur in health care settings. Since the release of the Institute of Medicine (IOM) report To rove is Human: Building a Safer Health classification a number of efforts have been aimed at specifically addressing the moot point of medication errors. (1) any researchers have compiled data about the impressed signs of medication errors and lay opened strategies to prevent their proceeding by examining computerized order memorandum (2) The Institute for Healthcare Improvement has initiated and published collaborative efforts related to reducing adverse mix with drugs events. (3) Experts agree that the majority of medication errors come into one's head as the result of a complicated health care system rather than an individual's performance. To date, however, the best practices to make sure safe medication systems have not been explicated fully

Medication delivery theorys can be improved by developing a better understanding of the nature of near misses or actual medication errors. That understanding be pendents in part on a willingness and opennes to share information and experiences in reliances of preventing a reoccurrence. A wealth of medication error information resides in national medication error databases, which affords the health care community the opportunity to explore medication errors in detail. Output derived from reliable and valid databases can provide extremely valuable information. Information as it was as textual descriptions of errors, providers (eg pampers physicians) reported to have made errors, models of medication errors, products reported to be involved in errors, causes of errors, factors that contribute to errors, and patient consequences then can be used at researchers, clinicians, administrators, and others to help intercept errors.

BACKGROUND

not many researchers or other experts have focused forward the specific problems associated with medication errors in the OR. Attention typically has focused upon overall patient safety, the civilization of hospitals, and new technologies (eg computerized order note bar coding). The primary emphasis has been identifying specific strategies that will be helpful in the wide majority of hospital units. skilled hands however, agree that errors come about in the OR and can follow in serious outcomes, including death or serious injury. For example, the Joint Commission upon Accreditation of Healthcare Organizations (JCAHO) has obtained sentinel adventure reports that include at least nine medication errors made in the OR. Of those, six springed in death and three in permanent disability. (4) Since the release of the IOM report, limited attention has been given to specialty areas, specific originals of errors that occur in surgical settings, and the appropriate risk prevention strategies.

Clinicians working in the OR and other perioperative settings find little information and not many literature references to guide safe medication practice in these unique settings. For example, in the ORs and conduct areas of a hospital, clinicians frequently have direct access to medications without the benefit of having a pharmacist involved in the medication review proces Medication orders commonly are given orally, or the give suck to must rely on a priority card that may not be present Oral orders often are transmitted end a mask, which can contribute to confusion about a medication's name, might or dose. Ephedrine easily could be interpreted as epinephrine, and 10000 units could whole like 1,000 units. When medications are ordered in conditions as it is as these, it can lead to serious complications.

In the OR, an additional point to be solved [i]or[/i] settled exists related to transferring medications to the sterile field. In many ORs, medications are remov from their original container in the way that they can be placed in succession the sterile field. If they are placed onward the sterile field without adequate and appropriate labeling, inherent risks exist. Another issue is that the RN may transfer medications to a surgical assistant who has limited knowledge of medications and their project dose, concentrations, or strengths.

The fast-paced nature of the OR, coupl with the complexity of care, may contribute to errors. Medication errors can come to pass because of lack of information regarding a patient's allergies, inadequate documentation, or inadequate communication between providers during shift changes. Medication errors also can take place as a result of having numerous providers involved in the patient's care as he or she stirs from preadmission testing to preoperative holding, the OR, the postanesthesia care unit, and back to a clinical inpatient unit or home