Medication Errors in Day Surgery Settings

Rodney W. Hicks, MSN, RN, ARNP, BC, MPA and Shawn C. Becker, BSN, RN, U. S. Pharmacopeia, Rockville, MD

Purpose

Medication errors are pervasive in today's healthcare settings. However, few researchers have investigated medication errors originating in day surgery. MEDMARX® is a national medication error reporting program that has more than 340, 000 medication error records. This secondary analysis of the MEDMARX database examined errors in day surgery.

Methodology

Structured queries were performed on the MEDMARX database. Error outcome category, node, type of error, cause of error, contributing factor, level of staff involved, product reported, and patient outcome fields were included in queries and analyses. Case reports of medication errors were analyzed to identify common trends and patterns.

Results

More than 600 individual medication error records were reviewed. The majority (96%) of errors did not result in patient harm. The Administering node was the most often reported (68%) point in the medication use process where the error originated. Omissions and improper dose/quantity (24.9% and 23.8%) were the most common types of error. Performance deficit was cited as the leading cause. Distractions were common. The number of unique products reported was 142. Case reports revealed problems related to the administration of ophthalmologic solutions, patient identification, the use of sedative medications, and administering medications for which patients had previously reported allergies.

Implications

Medication errors threaten the organizational efficiency that is fundamental to day surgery settings. The diversity of clinical conditions and their associated medication use are broad in this setting. As such, the goal of reducing the risk of a medication error must be addressed through multidisciplinary and systems-related changes. The examination of data sets such as this one provides helpful insights into common clinical problems and issues that can be addressed by identifying strategies to limit risks.

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