Medication Errors in the PACU

Medication Errors in the PACU Rodney W. Hicks, PhD, ARNP, Shawn C. Becker, MS, BSN, RN, Pamela E. Windle, MS, RN, CNA, BC, CPAN, CAPA, Dina A. Krenzischek, MAS, RN, CPAN

A collaborative research group examined seven years of PACU medication errors from the MEDMARX database. Descriptive statistics showed a comparison of medication errors in all ages from pediatric to adult to geriatric groups. Nine categories of medication errors were noted and a total of 3,023 errors were attributed to errors in prescribing, transcribing, dispensing, administering, and monitoring. Harmful errors were present in 5.8% of the sample, which included two patient deaths. Results indicated that errors can occur in any age group. Organizations and institutions should be aware of these occurrences to ensure vigilance at all times and to focus efforts toward avoiding or decreasing such errors. Patient safety and error prevention recommendations are provided. Keywords: patient safety, medication error, MEDMARX, postanesthesia nursing. Ó 2007 by American Society of PeriAnesthesia Nurses.

IN MARCH 2007 The United States Pharmacopeia (USP) released its seventh report to the nation on medication errors entitled MEDMARX Data Report—A Chartbook of Medication Error Findings from the Perioperative Setting from 1998–2005.1 This unique report focused on the perioperative continuum of care, beginning with outpatient surgery and moving to the preoperative holding area, operating room (OR), and postanesthesia care unit (PACU). This article summarizes selected findings from the report and discusses patient safety implications for postanesthesia nursing. MEDMARX is an Internet-accessible, anonymous medication error–reporting program that hospitals and related health systems use voluntarily as part of their ongoing efforts to improve safe medication use. Subscribers to the program are able to view, aggregate, and analyze their own medication errors as well as those entered by other participants. Since Journal of PeriAnesthesia Nursing, Vol 22, No 6 (December), 2007: pp 413-419

its creation in 1998, more than 870 participants have submitted more than 1.2 million medication error records. Background

The PACU is a critical care area providing Phase I nursing care for patients immediately after local, regional, and general anesthesia Rodney W. Hicks, PhD, ARNP, is Manager, Patient Safety Research & Practice, US Pharmacopeia, Rockville, MD; Shawn C. Becker, MS, BSN, RN, is Director, Patient Safety Initiatives, US Pharmacopeia, Rockville, MD; Pamela E. Windle, MS, RN, CNA, BC, CPAN, CAPA, is ASPAN Immediate Past President 20072008, and Nurse Manager, PACU, St. Luke’s Episcopal Hospital, Houston, TX; and Dina A. Krenzischek, MAS, RN, CPAN, is ASPAN Chair of Safety Committee, American Society of PeriAnesthesia Nurses, Cherry Hill, NJ, and Nurse Manager, PACU, Johns Hopkins Hospital, Baltimore, MD. Address correspondence to Rodney W. Hicks, U.S. Pharmacopeia, Center for the Advancement of Patient Safety, 12601 Twinbrook Parkway, Rockville, MD 20852; e-mail address: [email protected]. Ó 2007 by American Society of PeriAnesthesia Nurses. 1089-9472/07/2206-0008$35.00/0 doi:10.1016/j.jopan.2007.08.002 413

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associated with operative or invasive procedures. With recent advances in pain management and the increase in ambulatory procedures performed, PACUs can be highvolume areas with fast turnover of patients. PACUs are normally staffed by RNs with a wide range of backgrounds and expertise in areas such as critical care; plastic surgery; and emergency, orthopedic, cardiology, and gynecologic nursing. This experience accommodates the wide range of patients, including pediatric and geriatric populations, who pass through the PACU with procedures ranging from open heart surgery to radiographic and endoscopic procedures. The short turnaround time of patients and the nonresponsive or unconscious state of the majority of patients requires greater observation and monitoring to ensure a risk-free and safe experience in the PACU. Postanesthetic care of a patient includes frequent assessments, interventions, and monitoring of respiratory and cardiovascular functions (including hydration status), neuromuscular functions, mental status, pain status, nausea and vomiting, drainage and bleeding, and urinary output. At the end of successful Phase I care, patients can be transferred to another clinical area for Phase II recovery or they can be sent home. The PACU is a dynamic location that plays a key role in optimizing patient safety, recovery, and satisfaction and is an important area that requires considerable support from an institutional perspective.2 In April 2004, ASPAN adopted a position statement addressing safe medication administration.3 This statement signals that safe medication administration is a core competency for staff working in this environment. Staff members are also encouraged to know and implement evidenced-based facility policies related to medication usage, which ideally resulted from collaboration between physicians, pharmacists, and nurses. ASPAN3 also has a standard of care that is intended to promote and maintain a safe, comfortable, and therapeutic environment for patients, staff,

and visitors. The rationale for this standard is based on patients receiving sedatives/analgesia agents or anesthetic agents and the effect these agents have on motor and/or sensory function. The ASPAN Pain & Comfort Resource Manual provides guidelines and other supporting strategies intended to complement organizational policies and procedures to ensure that patients are cared for according to published standards.4 Pain management for children requires an extra level of caution, especially when providing split doses and doses based on weight in kilograms. There is limited research about medication errors in perioperative care in general, with most focusing on aspects of anesthesia errors,5-12 and even fewer focusing on errors in the PACU. In an earlier study that examined medication errors in the PACU between August 1998 and March 2002, as reported to MEDMARX, researchers found that 6.9% of the errors resulted in harm to the patient.13 In an additional study focusing on pediatric medication errors in the PACU reported to MEDMARX over a 6-year period, researchers reported that 20% of the medication errors were harmful, with half of the errors involving morphine, acetaminophen, meperidine, or fentanyl.14 The causes of these errors were multifactorial, but many resulted from breakdowns in communication, calculation errors, decimal point errors, the use of a leading/trailing zero, knowledge deficit on the part of the health professional, and dosage form confusion. Findings

Between September 1, 1998 and August 31, 2005, there were 397 facilities reporting errors into the MEDMARX program that originated in the PACU. More than 85% of the facilities were community hospitals, and most facilities reported bed capacity between 100 and 400. Collectively, these facilities submitted 3,260 records spanning all error categories. Based on the National Coordinating

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Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors, the categories are defined as: d d d

d

d

d

Category A: Circumstances or events that have the capacity to cause error Category B: An error that occurred but did not reach the patient Category C: An error that occurred and did reach the patient but did not cause harm Category D: An error that occurred, reached the patient, and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm Category E: An error that occurred which may have contributed to or resulted in temporary harm to the patient and required intervention Category F: An error that occurred which may have contributed to or resulted in temporary harm to the patient

d

d

d

and required initial or prolonged hospitalization Category G: An error that occurred that may have contributed to or resulted in permanent patient harm Category H: An error that occurred which required intervention necessary to sustain life Category I: An error that occurred which may have contributed to or resulted in the patient’s death (http://www.nccmerp.org)

There were 184 (5.6%) medication errors associated with harm and 11 cases were classified as sentinel events (Categories G, H, or I) including two patient deaths (Table 1). This reported rate of harm is more than four times the rate of harm associated with all other medication errors reported to MEDMARX during the same time period. Case example 1. An elderly postoperative patient with a dialysis catheter was in the

Table 1. Error Severity for PACU Medication Errors by Patient Population All Records Error Category

n

Pediatric

Adult

%

n

%

7.3

0

0

0

0

0

0

1

Actual Error, Reached the Patient but did not result in Harm Cy 1,506 46.2 40 67.8 818 Dy 419 12.9 7 11.9 218

Opportunity for Error A* 237

Actual Error, Did not Reach the Patient B* 914 28

Actual Error, Reached the Patient but did result in Harm Ey 155 4.8 10 16.9 Fy 18 0.6 0 0 Gy 2 0.1 0 0 Hy 7 0.2 2 3.4 Actual Error, Reached the Patient, Resulted in Death Iy 2 0.1 0 0 Total Records Percent Harmful

3,260

59 5.8

*For Categories A and B, age is not required. y For Categories C–I, age was not entered.

n

Geriatric %

%

n

0

0

237

16.3

0.1

0

0

913

62.8

72.1 19.2

417 143

68 23.3

231 51

15.9 3.5

82 11 1 3

7.2 1 0.1 0.3

46 4 1 1

7.5 0.7 0.2 0.2

17 3 0 1

1.2 0.2 0 0.1

1

0.1

1

0.2

0

1,135 20.3

n

Age not Provided

613 8.7

%

0

1,453 8.8

1.4

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PACU. The nurse planned to maintain the catheter by instilling a 2-mL heparin flush (200 units of heparin). The nurse obtained the wrong concentration of heparin and administered 10,000 units of heparin through the dialysis catheter. As a result of the excessive dose, the patient developed severe hypotension and bleeding. The patient died 10 hours later despite aggressive care. As a result of the error, the staff updated the current policy and adopted a new policy that only dialysis nurses would care for such catheters.

Case example 2. A surgeon wrote postoperative orders on the intensive care order form for an adult patient to receive mannitol. The orders were not acted upon until the patient was transferred from the PACU to the intensive care unit nearly 5.5 hours later. As a result of the delay in receiving mannitol, the patient’s intracranial pressure significantly increased. The staff reviewed the incident and determined that there was a breakdown in communication in that orders not written on the perioperative report were presumed to be started by the floor when the patient was transferred from the PACU.

Of the total medication errors submitted (n 5 3,260), there were 59 records (1.8%) involving pediatric patients and these came from 42 facilities. There were 1,135 records (34.8%) involving adult patients from 287 facilities and 613 records (18.8%) involving geriatric patients from 215 facilities. A higher percentage of harmful records was reported in the pediatric population than in the adult or geriatric populations (20.3% compared with 8.7% or 8.8%). Some of the records did not contain age (ie, data were missing) or the level of error severity did not require an age (ie, Category A and Category B records).

The majority (79.1%) of medication errors involved either a prescribing error, an error of improper dose/quantity (wrong amount), an omission error, or an unauthorized/wrong drug error. Compared with the general MEDMARX data, when a prescribing error occurred, it often involved inaccurately completing preprinted orders or writing medication orders that were contraindicated because of a patient’s preexisting allergy. Errors involving administration of the wrong amount of medication were attributed to misprogramming patient-controlled analgesia (PCA) pumps (which delivered an excessive amount of analgesia), calculation errors, and dose versus volume confusion (eg, 0.6 mg vs 0.6 mL). Omission errors were often associated with antimicrobial agents. Wrong drug errors were attributed to product names that either sounded or looked alike, resulting in the wrong product being given, such as the case with hydromorphone and morphine. Wrong

Slightly more than half (50.3%) of the medication errors occurred during the point of drug administration, whereas slightly more than one quarter of the medication errors (28.4%) originated during the prescribing phase of the medication use process. This finding of the disproportionately large percentage of administration errors was also noted in each of the populations (Table 2).

Table 2. Medication Use Process and PACU Medication Errors by Patient Population All Records

Pediatric

Adult

Geriatric

Age not Provided

Node

n

%

n

%

n

%

n

%

n

%

Prescribing Transcribing/Documenting Dispensing Administering Monitoring

858 370 220 1,521 54

28.4 12.2 7.3 50.3 1.8

18 4 6 49 1

23.1 5.1 7.7 62.8 1.3

179 110 69 751 26

15.7 9.7 6.1 66.2 2.3

88 68 29 411 17

14.4 11.1 4.7 67 2.7

573 188 116 310 10

47.9 15.7 9.7 25.9 0.8

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drug errors also occurred when the staff retrieved the wrong product from automated dispensing devices. For example, one case reported that the nurse intended to obtain an antiemetic agent but reached into the adjacent compartment and withdrew phenylephrine. As a result of the patient receiving the wrong medication, the length of time in the PACU was increased to manage the effects of the phenylephrine. Case example 3. A surgeon wrote an order for morphine 0.2 mg (packaged 10 mg/mL) to be administered to an infant after surgery. The PACU nurse administered 0.2 mL of morphine (equivalent to 2 mg or 10-fold overdose), which suppressed the respiratory function. The PACU team successfully performed CPR on the child and transferred the child to the pediatric intensive care unit for additional monitoring. As a result of the error, the performance improvement activities included obtaining medications in pediatric formulations and dedicating staff and PACU space for pediatric patients in an area different than where adult patients received care. Another type of medication error reported, though less frequently, was wrong route errors. These errors were medications intended for one route of administration that were inadvertently given via another route. For example, antimicrobial agents intended for parenteral administration (such as intravenous piggyback) were connected and infused through epidural lines, and epidural medication infusions were connected to intravenous lines. One of the harmful cases described an antimicrobial agent (via intravenous piggyback) that was connected to a ventricular ostomy drain. Other wrong route errors included intravenous fluids connected to Foley catheters as bladder irrigants. The study found that 366 different products had been involved in medication errors in PACU settings. Slightly more than one third (39%) of the products involved shared the

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same therapeutic class of central nervous system agents used in connection with pain management and included products such as morphine (17.6%), meperidine (6.5%), hydromorphone (6%), and fentanyl (4.4%), findings that would be consistent internally with the practice setting. Just more than half (56.5%) of the harmful medication errors involved central nervous system products. Other therapeutic classes involved in errors included antiinflammatory agents (eg, ketorolac), anticoagulants (eg, heparin), and antiemetic agents (eg, promethazine).

Discussion and Implications The MEDMARX data report is the most comprehensive known analysis of more than 11,000 perioperative medication errors and provides further evidence for many standardof-care activities and improvements. Voluntary medication error reporting systems are viewed as one means of reducing harmful medication errors. Such systems can work toward this goal through open sharing of medication error information as well as sharing ‘‘lessons learned.’’ Participating in such reporting programs is one of the key recommendations included in the data report. The complete report highlights fragmentation of the perioperative continuum of care and unavailability of valuable patient information at the required time or place. The PACU, as part of the continuum, had medication errors affecting all patient populations, with nearly 6% of the errors resulting in harm. Though slightly less than the incidence of harm reported in the OR (7.2%), the PACU exceeds the baseline harm ratio of 1.3% and is more than the 3.3% associated with medication errors reported in intensive care units.15 The large percentage of administration errors (50.3%) suggests an immediate area needing performance improvement activities, especially in light of administration errors reported in less than 30% of this historical average

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of medication error events reported to MEDMARX. Traditionally, for nursing, the ‘‘5Rights’’ have guided safe medication administration. Recently, The Appellate Court of Illinois ruled that hospitals are responsible for the negligence of their nursing staff members who carried out physician orders by giving a medication that was clearly contraindicated for the patient. In essence, the ‘‘5-Rights’’ are being replaced with ‘‘7-Rights’’ by adding the right indication and the right documentation. Many of the errors occurred during the PCA process. The PCA order dictates the parameters that are programmed into the PCA device (pump) and includes the analgesic product, the bolus dose (if any), the lockout interval, dose limits, and the basal (background) infusion rate.16 Although a PCA enables the patient to self-administer a dose of analgesic when needed, each step of the PCA process has an effect on the safety associated with using the PCA. Future improvements in PCA pumps are likely to include decision support rules as well as bar code readers to ensure accuracy of the right product and the right dose during the setup of the device. Because of the number and severity of medication errors associated with PCA pumps, organizations are encouraged to perform a Failure Mode and Effects Analysis (FMEA) to begin addressing safety concerns. To reduce the potential for dose-versus-volume errors, organizations are encouraged to explore purchasing different doses based on the population served. In addition, facilities should only purchase drug products that are labeled according to total volume content so the healthcare professional can avoid dose-versus-volume errors. This means that a vial could have 100 mg total content and vial contains 10 mL, resulting in a concentration of 10 mg/mL. If the vial was prominently labeled as 10 mg/ mL, the person holding the vial may inadvertently think that the entire contents equaled 10 mg. By clearly labeling the total content as 100 mg, a practitioner would be less likely to use the whole vial when obtaining a 10-mg

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dose. Final ready-to-use dosing is preferred over manual manipulation of syringes or cartridges. Drug calculation errors, especially in pediatric patients, represent a significant threat to patient safety. Ensuring calculations are accurate through the medication use process by providing weight conversion charts is another key recommendation from the report. Such dosing charts should also contain maximum dosing guidelines. Dosing charts are inexpensive to create using readily available software and can be laminated fairly easily. The number of products involved in medication errors, as reported through the MEDMARX program, points to the need for up-to-date current medication references. Few publications are dedicated to the perioperative pharmaceutical aspect of care. Therefore, perioperative clinicians must rely on a variety of other sources covering numerous populations and interpret how the information relates to their specific practice. Increasing the role of the pharmacist and the support of the pharmacy department should be actively explored. When feasible, pharmacists should review all medication orders before drug administration. Balancing this suggestion with the demand on the pharmacy’s workload will require interdisciplinary collaboration and fiscal consideration. The pharmacy department can also assist with evaluating medications routinely stocked in the various perioperative areas and the dispensing devices used in these areas, as well as the par levels of various bins or drawers. Careful attention must be given to products (and strengths) that are available without pharmacist review. For example, restricting access to heparin with a concentration of 10,000 U/mL creates a forcing function that helps to ensure patient safety. An interdisciplinary team can also address standardizing medication concentrations and dosing to ensure that excessive amounts of medication

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are not available. An example here may be to have morphine routinely available in doses smaller than 10 mg/mL (such as 2 mg or 4 mg), which would still allow for dose titration. The interdisciplinary team can also ensure that abbreviation use is in line with the Joint Commission’s standards as well as the National Patient Safety Goals. Ensuring medical devices and corresponding tubes are connected correctly is paramount to reduce the possibility of wrong route errors. Vigilance is required to trace the origin and insertion of all tubes connected to the patient. Professional organizations and health care facilities are called on to encourage manufacturers to engineer solutions that prevent any type of misconnection.

Conclusion Although much national attention has been directed at medication errors in general, relatively little information has been made

available to guide medication safety in the PACU. Recognizing the types and causes of medication errors, especially those that result in harm, can direct future safe medication use. ASPAN guidelines, expanding the pharmacy role in the PACU, and providing specific dosing charts are areas that can be explored immediately. Developing safeguards around the PCA process is another area that warrants immediate attention. PACU nurses are also vulnerable to errors. With the busy pace, the severity of many postoperative patients in the PACU, and the need to move patients through the recovery phase, human factors of health care workers can potentiate the possibility of errors at the point of drug administration. PACU nurses need always remain vigilant in terms of awareness, diligence, checking and rechecking medications before each medication administration, and recognizing that even in the best of conditions, medication errors can still occur.

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8. Jenson L, Merry A, Webster C, et al. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004;59:493-504. 9. Khan FA, Hoda MQ. Drug related critical incidents. Anaesthesia. 2005;60:48-52. 10. Liu E, Koh K. A prospective audit of critical incidents in anaesthesia in a university teaching hospital. Annual Acad Med (Singapore). 2003;32:814-820. 11. Orser BA, Byrick R. Anesthesia-related medication error: Time to take action. Canadian Journal of Anaesthesia. 2004; 51:756-760. 12. Wheeler SJ, Wheeler DW. Medication errors in anaesthesia and critical care. Anaesthesia. 2005;60:257-273. 13. Hicks RW, Becker SC, Krenzischeck D, et al. Medication errors in the PACU: A secondary analysis of MEDMARX findings. J Perianesth Nurs. 2004;19:18-28. 14. Payne CH, Smith CR, Newkirk LE, et al. Pediatric medication errors in the postanesthesia care unit: Analysis of MEDMARX data. AORN J. 2007;85:731-740; exam 741-744. 15. Santell JP, Hicks RW, Cousins DD. MEDMARX Data Report. A Chartbook of 2000-2004 Findings from Intensive Care Units and Radiological Services. Rockville, MD: USP Center for the Advancement of Patient Safety; 2005. 16. Macintyre PE. Safety and efficacy of patient-controlled analgesia. Br J Anaesth. 2001;87:36-46.