Medication safety—reliability of preference cards

AORN Journal,  Sept, 2005  by Anthony Dawson,  Michael J. Orsini,  Mary R. Cooper,  Karol Wollenburg

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Medication use in perioperative settings involves a complex process that has the potential to result in serious errors. During a surgical procedure, different medications are added to the surgical field, and this can increase the risks of mishaps at any stage of the medication delivery process. Possible problems include

* misidentification of medications or solutions;

* inadvertent intravascular or organ infusion of a potentially toxic substance;

* infusion and infusion-device problems;

* timing of medication administration, specifically of preoperative antibiotics;

* miscommunication of verbal orders; and

* outdated preference cards. (1)

This article describes an analysis of preference cards that was conducted as part of an overall evaluation of the intraoperative medication-use process at a major metropolitan academic medical center. The objective of the analysis was to ascertain the medication-error potential associated with the use of the preference card system. A secondary subanalysis was performed to evaluate the process of using and maintaining the cards.

MEDICATION SAFETY DURING SURGERY

The American Society of HealthSystem Pharmacists defines a medication error as

   any preventable event that may
   cause or lead to inappropriate medication
   use and patient harm while
   the medication is in the control of the
   health care professional, patient, or
   consumer. (2(p165))

Such events may be related to professional practice; health care products; procedures; and systems, including prescribing, communicating orders, labeling products, packaging and nomenclature, compounding, dispensing, distributing, administering, educating, monitoring, and using. (2)

Preventing medication-related errors is a goal shared by many national professional organizations. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has incorporated medication safety goals into its standards (3) and has revised its medication management standards for 2006 to

   ... increase safe practices surrounding
   the selection and procurement of
   medications; address safe medication
   management practices for medications
   that are brought into an organization
   by a licensed independent
   practitioner; and address risks associated
   with medications that are used
   as part of a procedure, regardless of
   whether there is a specific order for
   the medication. (4)

AORN has emphasized the importance of safe medication practices in the OR by recommending practices for health care providers to manage and administer medications on the surgical field. (5) The Institute for Safe Medication Practices (ISMP) has presented case studies of mix-ups and misinterpretations on the surgical field, along with safe practice recommendations to prevent these types of mishaps from occurring. (6)

Opportunities exist for improving medication safety during surgery. An analysis of medication error reports submitted to the US Pharmacopeia's MEDMARX reporting system found that 731 of 150,000 medication events occurred in the OR. Ten percent of the reported OR medication errors resulted in temporary or permanent harm or death. (7) Errors involving medications commonly administered on the sterile field accounted for 19% of all reports. (7)

Many of the OR error reports involved problems with preoperative antibiotics or medications given by anesthesia care providers. (7) After undertaking an extensive self-study of medication errors encountered in the practice of anesthesiology, anesthesia care providers have built a body of work that demonstrates their accomplishments in improving medication safety. (8-12) They succeeded in reducing anesthesia errors through better use of technology, standardized guidelines and protocols, and the adoption of an approach to patient safety that embraced human factors and improved systems. The use of patient simulation for research, training, and performance assessment has further contributed to this accomplishment. (8)

Very few studies have examined medication-error risk during surgery with respect to medications that are prepared and administered on the surgical field. Systems that support safe medication practices can reduce the incidence of medication errors, (13-16) but many established medication safety practices have yet to be adopted in ORs. Although guidelines and recommendations have been published to address some of the issues regarding intraoperative medication use on the sterile field, (5) a comprehensive systems analysis of this process has not appeared in the literature. Furthermore, no one has combined the various recommendations published by national professional organizations in an effort to build a safer system.

ANALYSIS OF SURGEONS' PREFERENCE CARDS

Many ORs in hospitals throughout the United States use preference cards to communicate physician preferences for each surgical procedure. Traditionally, preference cards contain important information, such as specific supplies needed for the procedure, special equipment, the surgeon's preference for setup and positioning, and other detailed instructions. In addition, preference cards essentially serve as the physician's orders for medications that the surgeon typically uses for a given procedure. Systems for maintaining these cards include use of both electronic data files and handwritten changes.