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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BRAND VERSUS GENERIC NAME. Although hospital policy requires that generic names be used for all medications, only 24% of the preference cards listed medications exclusively by generic names. Medication names typically appeared as a combination of brand and generic names. On 75.8% of the cards, brand and generic names were used interchangeably on the same card, and the brand and generic names did not always match (ie, the incorrect generic name was listed for a brand or vice versa).

ADDITIONAL FINDINGS. Among other findings, some preference cards specifically called for the use of restricted antibiotics, such as vancomycin. Other preference cards listed a particular medication package size (eg, epinephrine 1:1,000, 30 mL vial) that was not available to OR personnel.

The most significant additional finding appeared to be that the medication listed on the preference card did not match the medication being used in the procedure. For example, in one case, 1 mg epinephrine was mixed with 20,000 units of thrombin for topical administration, but epinephrine was not listed on the preference card for that type of procedure. Another procedure relied on a card that had no local anesthetics listed. Although bupivacaine did not appear on the card, bupivacaine 0.25% routinely was used by the surgeon. Examples of additional errors found in the sample include

* bupivacaine 0.25% with epinephrine 1:200,000 listed under supplies and bupivacaine 0.25% with no epinephrine listed in medication instructions;

* ferric subsulfate referred to on the card as ferrous sulfate; and

* gentamycin sulfate ointment 0.1% package size listed as 5 g--the smallest size available at that strength is 15 g.

SUBANALYSIS II: FMEA RESULTS

The detail of the map of the preference card process constructed by the FMEA team (Figure 1) reveals the presence of multiple steps with a number of potential system failure points throughout. A total of 22 decision points, or steps, were identified in the preference card process. Four of these steps were highlighted as targets for more in-depth analysis based on the actual experiences of the team members. Table 2 includes these four target steps along with 12 individual failure modes associated with the steps.

[FIGURE 1 OMITTED]

The FMEA team was asked to assign a criticality score for each of the 12 failure modes that were identified. Criticality scoring helps determine how harmful a failure mode may be if it is allowed to occur, and also helps to prioritize corrective action initiatives. (18,19) The higher the score, the greater the chance of harm.

To determine criticality, team members were asked to score each of the failure modes using three variables (ie, severity, frequency, likelihood of detecting error). The scoring for each variable was on a 10-point scale, as follows:

* severity of effect (1 = no effect, 10 = death);

* frequency of failure (1 = never occurs, 10 = happens often); and

* chance of detecting error (1 = always detected, 10 = never detected).