Medication Errors in the Operating Room

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

Purpose

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

Methodology

Structured queries indicating OR as location of error were performed on the 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 issues and practice patterns.

Results

More than 720 medication error records were reviewed. The majority (90%) of errors did not result in patient harm, though a few (n=3) resulted in either a near death experience or fatality. The Administering node was most often reported (62%). Omissions and improper dose/quantity (26.5% and 16%) were the most common types of error. Performance deficit was cited as the leading cause of error. Distractions were common. There were 13 different provider types identified. The number of unique products reported was 147.

Implications

The surgical setting differs from other settings. Many orders are given verbally or originate from a preference card. Moving medications to the sterile field may result in having multiple unlabeled products available. High alert medications, including the "caines" and epinephrine are available in multiple dosage forms and concentrations. The goal of reducing the risk of a medication error must be addressed through multidisciplinary and systems-related changes with specific strategies to address the unique nature of the OR practice setting.

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