Archive October 2017 XVIII, No. 10

7 Tips to Prevent Medication Errors

Ensure the right dose of the right medication reaches the right patient.

Daniel Cook

Daniel Cook


patient care area FLYING SOLO The OR is one of the few patient care areas where a single person is often in charge of obtaining, preparing and administering medications.

Why do medication mistakes continue to occur? "Because too many surgical leaders have focused on weak interventions," says Joyce Wahr, MD, FAHA, vice chair of quality and safety in the department of anesthesiology at the University of Minnesota in Minneapolis. "You can change policies and procedures, and tell providers to try harder, but those are incredibly ineffective ways to address the underlying issues." Instead, says Dr. Wahr, focus on implementing fail-safe systems that stop mistakes as they're happening, before they reach the patient.

Mistakes? Yes, mistakes. A team of researchers observed nearly 3,675 medication administrations made during 277 surgeries. The results were eye opening: 124 of the cases involved at least 1 medication error (a mistake in ordering or administering a drug) or adverse drug event (harm or injury related to a drug, regardless of whether it was caused by an error). Of the 193 medication-related errors or adverse events they observed, nearly 80% were preventable.

One in 20 administrations — or 1 during every other operation — resulted in a medication error. One-third of the errors led to some kind of patient harm, ranging from skin rashes to changes in blood pressure or increased infection risk, and the remainder had the potential to cause harm.

The most common errors that led to patient harm involved wrong doses, omitted medications and failing to intervene when necessary, based on changes in the patient's condition. Karen Nanji, MD, MPH, an anesthesiologist at Massachusetts General Hospital in Boston, Mass., and her colleagues have implemented interventions designed to eliminate the types of errors they found. Can their practice improvements promote medication safety in your facility?

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