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Medication Errors in Post Anesthesia Care Units

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 with little research focusing on errors originating in post anesthesia care units (PACU). MEDMARX® is a national medication error reporting program that has more than 340,000 medication error records. This study involved a secondary data analysis of the reports occurring in PACUs.

Methodology

Structured queries indicating PACU as location of error were performed. 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 the analyses. Case reports were analyzed for common themes and medication use related problems.

Results

More than 640 individual medication error records were reviewed. The majority (93.1%) of errors did not result in patient harm. However, 6.9% did result in various levels of harm. The Administering node was the most often reported (60%) point in the medication use process where the error originated. Improper dose/quantity and omissions (24.1% and 20.6%) were the most common types of error. Performance deficit was cited as the leading cause of error. Distractions were frequently reported. The number of unique products was 131. The analysis of case reports detected problems with the management of both epidural and patient-controlled analgesia as well as problems with administering extra doses or omitting doses of medications. Patients appeared to receive medications for which they had previously reported allergies.

Implications

The goal of reducing the risk of a medication error must be addressed through multidisciplinary and systems-related changes. Using a national database to identify trends in the nature and type of medication errors can assist members in the healthcare team to identify risk situations and implement appropriate preventative strategies.

View the poster  (226KB).