Outpatient Surgery Magazine

A Deep Dive Into Surface Disinfection - October 2017 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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Page 77 of 126

Mistakes? Yes, mistakes. A team of researchers observed nearly 3,675 medication administrations made during 277 surgeries. The results were eye opening: 124 of the cases involved at least 1 medication error (a mis- take in ordering or administering a drug) or adverse drug event (harm or injury related to a drug, regardless of whether it was caused by an error). Of the 193 medication-related errors or adverse events they observed, nearly 80% were preventable. One in 20 administrations — or 1 during every other operation — resulted in a medication error. One-third of the errors led to some kind of patient harm, ranging from skin rashes to changes in blood pressure or increased infection risk, and the remainder had the poten- tial to cause harm. The most common errors that led to patient harm involved wrong doses, omitted medications and failing to intervene when necessary, based on changes in the patient's condition. Karen Nanji, MD, MPH, an anesthesiologist at Massachusetts General Hospital in Boston, Mass., and her colleagues have implemented interventions designed to eliminate the types of errors they found. Can their practice improvements pro- mote medication safety in your facility? 1. Barcode-assisted syringe labeling. This technology was in place in most of Mass General's ORs during the study period, but 24% of the errors involved labeling mistakes when the technology wasn't installed or providers used workarounds to circumvent its use. If you're using barcode-assisted labeling, place the technology at the immediate point of care and make sure it's user-friendly and performs fast enough to keep up with the pace of surgery, says Dr. Nanji. She also recommends that you trial any platform you're thinking of imple- menting to make sure it's compatible with the complexity of deliver- ing medications in the OR. Also train your staff extensively on new 7 8 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 7 SURGICAL ERRORS

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