Suggestions to help prevent OR medication errors - Brief Article

AORN Journal,  Sept, 2002  

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Medication administration during a surgical procedure can pose challenges that present increased risk for errors. When a clinician both prescribes and administers medication, there is little chance that an error will be detected before the medication is administered. When one clinician prescribes medication and another administers it, the orders often are verbal. Verbal orders can lead to errors because clinicians wear masks that obscure their mouths, clinicians may not speak or hear clearly, music may be playing, or distractions may occur.

In a recent occurrence reported to the Institute for Safe Medication Practices, a surgeon verbally ordered 10,000 units of heparin for a patient undergoing a carotid endarterectomy. The anesthesia care provider heard and administered 2,000 units. The error led to low activated clotting times during the procedure, and the patient required additional doses of heparin.

The Institute for Safe Medication Practices recommends several measures to help avoid human error in intraoperative medication prescription and administration.

* The clinician administering medication should make a habit of repeating all verbal orders using a digit by digit technique (eg, one-five, not fifteen).

* A "read-back" system can be instituted in which the circulating nurse or an anesthesia staff member writes down the verbal order and reads it back to the prescribing physician.

* The name, dosage, and route of the medication can be repeated immediately before administration.

* The medication and dosage should be matched to the patient's condition and indication for use.

* Standard protocols can be instituted for administration of certain medications during surgery.

For more information about medication safety in the OR, please refer to "AORN guidance statement--safe medication practices in perioperative practice settings" published in the May 2002 issue of the AORN Journal.

J Smetzer, "Prescriptions for safety," AHA News (June 3, 2002) 6,

COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group