Harmful errors most likely in perioperative setting
Some 12% of pediatric med errors result in harm
A study released by the United States Pharmacopeia (USP) says perioperative patients face an increased risk of harmful medication errors throughout the surgery process due to a lack of comprehensive oversight of medications. The seventh annual national Medmarx Data Report released by the USP studied medication errors in the perioperative setting — including outpatient surgery, the preoperative holding area, the operating room, and the post-anesthesia care unit.
The Medmarx report looked at more than 11,000 medication errors in the perioperative setting and found that 5% of the errors resulted in harm, including four deaths. USP says 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.
According to USP, what many people generally call "surgery" is actually a system of several different departments that patients move 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," said USP Healthcare Quality Information vice president Diane Cousins, one of the report's authors. "The fragmented system creates a high risk for harmful medication errors."
The highest rate of harmful medication errors occurred in the operating room (7.3%). The post-anesthesia care unit had the next highest rate at 5.8%, followed by the outpatient surgery department at 3.3%, and the perioperative holding area at 2.8%.
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 that surgical staff better coordinate hand-offs.
Meanwhile, a special California Medication Errors Panel that spent a year taking testimony from experts in the field of medication errors says such errors are estimated to injure or kill 150,000 Californians each year and contribute to costs of more than $17 billion.
The in-depth report from the panel that was appointed by the legislature focuses on the causes of medication errors in the outpatient setting and recommends changing the healthcare system to protect consumers from errors associated with use of prescription and OTC medications.
"Not enough has been done in California to address this critical issue," said former state Sen. Jackie Speier, who introduced the legislation creating the panel. "The recommendations of the panel will save the lives of thousands of Californians and should be incorporated into legislation without delay."
In hearing from 32 invited speakers, the panel learned that:
- Medication errors are preventable and can occur at any point in the medication use process, including prescribing, transcribing, dispensing, using, and monitoring;
- Medication errors often are the result of problems associated with incorrect medication use by patients;
- Low health literacy is a significant contributing factor for many medication errors; and
- Using multiple medications increases a person's risk for experiencing a medication error, especially when they are prescribed by multiple providers and filled at multiple pharmacies.
The panel report contains 12 consensus recommendations for systemic change. Those recommendations are:
- Improve legibility of handwritten prescriptions and establish a deadline for prescribers and pharmacies to use electronic prescribing;
- Require that a medication's intended use by included on all prescriptions and require that the intended use of a medication be included on the medication label unless disapproved by the prescriber or patient;
- Improve access to and awareness of language translation services by pharmacists at community pharmacies and encourage consumers to seek out pharmacists who speak their language and understand their cultural needs;
- Promote development and use of medication packaging, dispensing systems, prescription container labels, and written supplemental materials that effectively communicate to consumers accurate, easy-to-understand information about the risks and benefits of their medication, and how and where to obtain medication consultation from a pharmacist;
- Identify and disseminate information about best practices and effective methods for educating consumers about their role in reducing medication errors;
- Establish an ongoing public education campaign to prevent medication errors, targeting outpatients and persons in community settings;
- Develop and implement strategies to increase the involvement of public and private sector entities in educating consumers about improving medication safety and effectiveness;
- Help ensure quality and consistency of medication consultation provided by pharmacists within and among pharmacies;
- Establish standards for Medication Therapy Management programs and create incentives for their implementation and ongoing use by pharmacists and other healthcare providers;
- Create training requirements for pharmacists and other healthcare professionals that address medication safety practices and related programs, including medication consultation and medication therapy management programs;
- Establish and support efforts to collect data regarding the nature and prevalence of medication errors and prevention methods for reducing errors, especially focused on persons at high risk for medication errors and on community, ambulatory, and outpatient settings; and
- Convene a panel of stakeholders to identify and propose specific actions and strategies to overcome barriers to qualified pharmacists being recognized and paid as healthcare providers.
[Editor's note: More information on the USP report is available online at http://www.usp.org. The California report is available online at http://www.pharmacyfoundation.org/medicationerrors.]
A study released by the United States Pharmacopeia (USP) says perioperative patients face an increased risk of harmful medication errors throughout the surgery process due to a lack of comprehensive oversight of medications.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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