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Medication Errors in Anesthesia

Discussion in 'Anesthesiology' started by White Owl, Dec 14, 2008.

  1. White Owl

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    Med student here presenting a topic shortly on medication errors, specifically related to anesthesia. I have done quite a few extensive internet searches (Google, Pub med, Anesthesiology, Anesthesia and Analgesia, CJA) and ven browsed through Barash with not a whole lot of luck. Anyone know any good journal articles or resources on the topic, especially on the indentification and elimination of these errors? Thanks a lot guys and gals.
     
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  3. Gern Blansten

    Gern Blansten Account on Hold
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  4. jwk

    jwk CAA, ASA-PAC Contributor
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    For better or worse, JCAHO has extensive standards and requirements dealing with medication and safety issues.

    Little things like labeling syringes (as opposed to not labeling), labeling them appropriately (with drug concentration), and of course the latest thing is not pre-labeling syringes. Obviously you have to pay close attention to labels on the drugs themselves. Far too many mistakes have been made because different meds come in similar-appearing vials. Color of the label/vial/cap etc. DO NOT indicate the drug or the amount of drug the vial contains. Standardized colors helps A LITTLE but not much.

    You'd be amazed what was considered appropriate 30 years ago when I started. We just stuck the syringe and needle in the bottle of the drug we'd drawn up (nobody used needle-less systems).
     
  5. pgg

    pgg Laugh at me, will they?
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    Wut?

    You mean my practice of unpacking and labeling the 30-ish syringes I'll need for the next day's CABGs runs counter the latest fad in clipboard nursing? What will they condemn next?

    Some people still do that. Or they tape the bottle to the syringe. I don't, because I'm an obedient little resident and I follow the rules ... but I'm not sure I believe it's the dangerously reckless behavior it's made out to be.
     
  6. Arch Guillotti

    Arch Guillotti Senior Member
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    Another article from the APSF:

    http://www.apsf.org/resource_center/newsletter/2008/fall/01_errors.htm

    Return to Table of Contents
    Medication Errors Persist
    Summit Addresses Intravenous Safety

    by Donald E. Martin, MD

    High Alert meds

    Intravenous medications have saved the lives of millions of patients. However, partly because of the huge number of doses and the number of different medications given daily, errors in IV medication administration still represent a significant health care problem in the United States today. It has been almost 9 years since the Institute of Medicine’s Report “To Err is Human” shocked the public consciousness and the medical establishment in 1999.1 Since then, much has been said and written about the problem, and there have been some significant steps forward. The Joint Commission has made reduction of medical errors one of its national patient safety goals for the past several years. In 2006, the FDA mandated that manufacturers include a machine readable bar code on the label of the containers of many prescription drugs. New technology such as bar codes, radio frequency identification (RFID), and computerized order entry (CPOE) systems have all come on the horizon as technological solutions, only to create different problems which may be almost as big as those they are intended to solve.

    It is painfully obvious that we are as yet nowhere near a solution, even for the so called “high alert” medications! The administration of flush solution with a heparin concentration 1000-times that intended to 17 Texas neonates in Corpus Christi on July 4 this year is just one very recent example of how far we have to go.

    According to the 2006 Institute of Medicine Report “Preventing Medical Errors,” on average, a hospitalized patient is subject to at least 1 medication error per day, with at least 1.5 million preventable adverse drug reactions occurring each year. These reactions lead to an estimated $3.5 billion in additional health care costs annually to hospitalized patients alone, and reactions to drugs represent between the fourth and sixth leading cause of deaths in hospitalized patients.

    According to an analysis of over 73,000 intravenous drug errors reported to the US Pharmacopoeia MedMarx database between 2000 and 2004, more than 50% of errors were in the process of actually administering medications, and 60% of these errors occurred in the intravenous administration of 1 of 20 “high alert” medications (Table 1). Between 3% and 5% of these reported errors led to patient harm.

    In the MedMarx database, one-half of errors occurred on patient units or nursing floors. However, 5% occurred in the operating room or in the pre- or post-anesthesia care units, where anesthesiologists and nurse anesthetists routinely practice. In the operating room, it has been estimated that 1 drug administration error occurs for every 133 anesthetics.2 Approximately 1% of these errors actually cause patient harm. Therefore, elimination of medication errors represents a tremendous opportunity to save lives and improve patient care in the OR as well as in the remainder of the hospital.

    In order to save lives and prevent harm to patients, far reaching changes are needed in the way medications are prepared and administered. The persistence of the problem has led to a new sense of urgency on the part of many organizations dedicated to patient safety, including the Institute of Medicine (IOM), the Institute for Safe Medical Practice (ISMP), Emergency Care Research Institute (ECRI), Joint Commission, Food and Drug Administration (FDA), Centers for Medicaid and Medicare Services (CMS), National Patient Safety Foundation (NPSF), United States Pharmacopeia (USP), Agency for Healthcare Research and Quality (AHRQ), the Institute For Healthcare Improvement (IHI), the National Quality Forum (NQF), and many other professional and specialty organizations.

    Representatives of these and other national organizations joined in an intensive 2-day Intravenous Safety Summit convened by the American Society of Health System Pharmacists (ASHP) in Rockville, MD, on July 14-15 to recommend very specific and attainable changes in practice that will be effective in preventing medication errors and saving lives now lost to adverse drug events. One of the real strengths of this summit was the integral involvement of frontline practitioners—nurses, physicians, and pharmacists, as well as vendors, health system experts, and researchers. Three participants in the summit represented the specialty of anesthesiology: Jeffrey B. Cooper, PhD, represented the Anesthesia Patient Safety Foundation; Donald E. Martin, MD, represented the American Society of Anesthesiologists; and Nathaniel M. Sins, MD, represented Partners Healthcare and brought unique expertise in the emerging “smart pump” technology.

    Specific recommendations from the summit are yet to be finalized. However, the themes for these recommendations were clear from the discussion and included

    1. The standardization of infusion concentrations and the units or format used to order or prescribe intravenous medication infusions (such as mcgm/min vs. mcgm/kg/min).
    2. Simplifying the administration process, with preference for the preparation of intravenous medication in the pharmacy rather than at the point of care.
    3. Obtaining the maximum benefit from technology in the form of bar codes, computerized order entry, and smart pumps.
    4. Establishing a culture conducive to medication safety.

    The specialty of anesthesiology and the practice of nurse anesthesia are both in very good positions to take leading roles in research, practice changes, and cultural changes needed to save lives now lost due to medication errors. Anesthesiologists are one of the few groups of physicians who are personally responsible for drug administration. Historically, our specialty has been able to effectively design monitors and ventilation systems and to greatly reduce death due to hypoxia or ventilatory failure in anesthetized patients. Anesthesiologists already have effective patient safety, “standards,” and “practice advisory” infrastructures in place. Significant research has already been done to evaluate drug administration procedures and technology to improve safety of drug administration during anesthesia (Table 2). All of these improvements have a potential to improve the process of drug administration in the operating room, which is a complex collection of more than 40 steps, if used to enable anesthesia providers to work more safely, as well as more quickly and efficiently.

    Establishing a “culture of safety,” however, may be more difficult than developing technology. Stabile, Webster, and Merry, in the Fall 2007 issue of the Anesthesia Patient Safety Foundation Newsletter, called for just such a cultural shift in medicine, from a culture of productivity to a culture of safety. In their words, “safety should be funded because it is the right thing to do, not because of any ROI directives.” Commercial aviation and other similarly complex yet high-risk industries adopted a culture of safety years ago. Medicine can do no less.

    Therefore, as a very important next step, the Anesthesia Patient Safety Foundation is planning a Board of Directors’ Workshop for Friday, October 17 in Orlando, FL, entitled “Innovations in Medication Safety in the Operating Room.” The workshop is designed to identify solutions for medication errors in the operating room that are currently technologically feasible, as well as ideas for potential new processes to be developed and explored. Participants in this workshop will include physicians, pharmacists, health systems and technology researchers, as well as representatives from the Joint Commission and other regulatory agencies. The very practical solutions coming from this workshop, as well as the ASHP IV Medication Safety Summit may well provide the innovations in drug administration processes, as well as insight into the human factors responsible for inevitable human errors, which are needed to bring about a true reduction in medication errors in the operating room.

    Table II

    Dr. Martin is Professor of Anesthesia at Penn State University College of Medicine in Hershey, PA. Dr. Martin is also Chair of the ASA Committee on Equipment and Facilities.
    References

    1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Committee on the Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press, 1999.
    2. Fasting S, Grisvold S. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anaesth 2000;47:1060-7.
    3. Jensen LS, Merry AF, Webster CS, et al. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004;59:493-504.
    4. Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia 2005;60:220-7.
    5. Orser BA, Oxorn DC. An anaesthetic drug error: minimizing the risk. Can J Anaesth 1994;41:120-4.
    6. Currie M, Mackay P, Morgan C, et al. The “wrong drug” problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:596-601.
    7. FDA Issues Bar Code Regulation. February 25, 2004: United States Food and Drug Administration. Available at: http://www.fda.gov/oc/initiatives/barcode-sadr/fs-barcode.html. Accessed August 25, 2008.
    8. Kaushal R, Bates DW. Information technology and medication safety: what is the benefit? Qual Saf Health Care 2002;11:261-5.
    9. Merry AF, Webster CS, Mathew DJ. A new, safety-oriented, integrated drug administration and automated anesthesia record system. Anesth Analg 2001;93:385-90.
    10. Merry AF, Webster CS, Weller J, et al. Evaluation in an anaesthetic simulator of a prototype of a new drug administration system designed to reduce error. Anaesthesia 2002;57:256-63.

    Return to Table of Contents
     
  7. jwk

    jwk CAA, ASA-PAC Contributor
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    Ha - it's not just the nurses. We have pharmacy nazis at our place.
     
  8. drmwvr

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    Oh, the pharmacy is the latest mob of jack-booted thugs to take the stage. Pre-op nurse told me the other day that a patient with an alleged "cephalosporin" allergy had been ok'd by the pharmacist to get his pre-op ancef pre joint replacement. He made the determination based on the reaction code (rash) on the hospital pharmacy information web, but what was really scary was that the surgeon was never contacted by the RN at all. Ancef was spiked and hanging.
     
  9. pgg

    pgg Laugh at me, will they?
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    Well, that tops my nurse preop antibiotic story.

    Vancomycin dripping in slow. Nurse opens it up because she was afraid the antibiotics wouldn't be infused in time to meet the pre-incision time requirements on the paperwork.

    My first clue: patient says, "Man, I'm really itchy."
     
  10. drmwvr

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    Yeah, you just can't win. Vanco wide open, zofran 10 mics every 5 mins 'till its in.
     
  11. nutmegs

    nutmegs ASA Member
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    key words: STARTED within 60 minutes before incision...
     
  12. rsgillmd

    rsgillmd ASA Member
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    Actually, I think with Vanco its 2 hours (120 minutes).

    At our hospital we put our Vanco on a pump. If you are not going to put it on a pump, you must spike it with a microdrip.
     
  13. proman

    proman Member
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    We require antibiotic infusions to be completed prior to incision. With vanc, it's within 2 hours, for Cipro it's within 1 hour. Makes more sense if you're considering serum levels & targeted MIC.
     
  14. proman

    proman Member
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    We require antibiotic infusions to be completed prior to incision. With vanc, it's within 2 hours, for Cipro it's within 1 hour. Makes more sense if you're considering serum levels & targeted MIC.
     
  15. nutmegs

    nutmegs ASA Member
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    Makes sense, yes. But our antibiotic START time is the one that is heavily (and more heavily every day) tied in with our reimbursements. I wonder where the state to state difference happens?
     
  16. bubalus

    bubalus Member
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    You may want some visuals for your presentation. Bring a few similar appearing vials containing vastly different drugs--similar size, glass (clear vs amber), cap color, etc. I've seen bottles/vials of vasopressin and atropine that look disturbingly similar. Bring a 10 mg vial of phenylephrine (what happens if you give the whole vial by accident?). How many units of insulin are in 1 ml? Ask some attendings what mistakes they have heard of. Prefilled syringes help with the labeling issue, but won't necessarily stop someone from grabbing the wrong syringe.
     
  17. nutmegs

    nutmegs ASA Member
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    how about Nimbex (cisatricurium) and Precedex (dexmedetomidine) with the identical teal tops when pharmacy puts the expiration date sticker over the first half of the brand name???
     
  18. pgg

    pgg Laugh at me, will they?
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    Well, you know, a good slug of Nimbex is even more effective than Precedex for chilling out those unruly agitated ICU patients. They quiet down right quick.

    At the childrens hospital where I am now, the pharmacy puts WARNING PARALYZING AGENT stickers on the vials of muscle relaxant. It's especially irritating when it covers the actual name of the drug and/or makes it impossible to peel the convenient Zemuron sticker off the vial.

    I'm not sure why they think they need to remind anesthesiologists what succ or roc do, or why they don't put WARNING MAKES PEOPLE SLEEPY stickers on propofol or WARNING IF BROKEN THIS VIAL MAY HAVE SHARP EDGES stickers on, well, everything.
     
  19. aphistis

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    :laugh:
     
  20. dfk

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    so, if abx are completed in the pre-op area, and your current case runs 1.5 hours over, are you still "covered"? why i ask, is because at my institution, they want incision within 1 hour of start of abx.
     
  21. psychbender

    psychbender Cynical Member
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    Yes, since the goal is to obtain MIC prior to incision, and maintain concentration above MIC for the duration of the procedure. Antibiotics should be administered up to one hour prior to incision (2 hrs if vancomycin or fluoroquinolones), and redosed if still in the operation >2 half-lives after the drug was administered.
     
  22. dfk

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    at what point would MBC outweigh MIC? or would it not? to me, something that kills at 99.9% would behoove something that inhibits at 99%. in any event, i suppose each institution has their own determinants of when the abx is sufficient in time to start administration.
     
  23. coprolalia

    coprolalia Bored Certified
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    This is more P4P nonsense. The reason why departments are getting so tough on this is because CMS is going to withold payment if the "before incision" antibiotic isn't documented within the timeframe. Don't be surprised when insurance companies follow.

    Here are some rhetorical questions that illustrate how stupid this idea is...


    • Vancomycin started few minutes before incision on hardware revision to knee. Tourniquet is going on affected leg. Has minimum inhibitory concentration been reached in extremity before leg? Do you delay the case?
    • Patient gets 1gm cefazolin in holding area at 7:11 AM. Delay getting patient to room. Surgeon is ready to incise skin at 8:12 AM. Do you re-dose the cefazolin?
    • Ampicillin and gentamicin ordered for belly exploration. For some reason there is a delay getting drugs from the pharmacy. Patient is unstable and sick SICU player with perfed viscus, already intubated. Do you wait to start case until you have the antibiotics?
    These are real scenarios that happen everyday. The irony is that the bean-counters will pay you in the first case based on what you wrote despite that you haven't had adequate antibiotic levels on board, but they won't pay you in the next two if you do the right thing (don't re-dose, and start the case without the abx).

    This is more and more the protocolizing of medicine. They are taking the thinking out of the equation, which is scary. People are very comfortable with the "checksheet" mentality. They often seem to care more about putting the right "tick" mark in the box than they do about doing the right thing.

    And, probably in the majority of the time, following that ticksheet will be the right thing to do. It's the margins that worry me. There's no contingency for the margins. And, now they're not going to pay you unless you write the thing they want to see on the paper. So, we're either forced to lie (fraud) or not get paid (unacceptable) or have to write a friggin' thesis about why we did or didn't do something (inefficient and uneffective care).

    It's madness, I tell you. Throw them all in the river, I say.

    -copro
     
  24. pgg

    pgg Laugh at me, will they?
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    Hmm, I have this funny feeling that the day my paycheck depends on it, all of my patients' anesthesia records will reflect receipt of antibiotics 25-35 minutes before incision and a PACU temp of 36.5 - 36.8 ...

    Interestingly enough, our automated anesthesia record system documents preop antibiotics exactly 30 minutes, to the second, before you hit the "surgeon cut" button (we manually fill in the drug and dose). Other event buttons also automatically insert other comments like "all pressure points check and padded" and "eyes taped" after the intubation button, or "airway suctioned" and "spontaneous ventilation" after the extubation button.

    Someone ought to program in a random number generator to make the automatically inserted times look more human. :)

    I wonder what kind of legal footing these computer-generated assertions of care or monitoring will have.
     
  25. nutmegs

    nutmegs ASA Member
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    wow. the one that automatically times your antibiotic start seems REALLY shaky, given that I think it's both a JCAHO and CMS measure. (I agree, a bull**** one in some cases, but still... artificially generating that seems clearly wrong).


    we just started a new p4p that involves giving beta blockers in the 24 hours around surgery to those on chronic beta blockers. where the **** is the evidence for that one? fortunately, just documenting "patient took atenolol at 5am" on the preop fulfills it, but there were also suggestions of pushing trivial amounts of esmolol to meet the requirement. f that.
     

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