Perioperative medication errors in otolaryngology

Perioperative medication errors in otolaryngology
Rebecca Rosenwasser 1, Almut G. Winterstein, PhD 1 2, Amy F. Rosenberg, PharmD, BCPS 5, Eric I. Rosenberg, MD, MSPH 3, Patrick J. Antonelli, MD 4 *

The authors have no funding, financial relationships, or conflicts of interest to disclose.
Medication • error • patient safety • perioperative • Level of Evidence: 4

Medication errors are a common cause of poor clinical outcomes. Information on perioperative medication errors is scarce. This study was aimed at identifying the nature, cause, and potential remedies for medication errors in otolaryngologic surgery.

Study Design:
Prospective and descriptive.

Clinicians were incentivized for reporting possible medication errors that occurred from the preoperative through the first postoperative clinic visit over a 2-month period. Each report was investigated by an expert panel to determine validity, preventability, contributing factors, and potential preventative measures. A random sample of procedures and clinic visits were monitored for compliance with safe medication practices and information flow.

From 589 surgeries, 20 medication errors were reported (two preoperative, four operative, five during hospital admission, two in transition between services, four during discharge, and three postoperative). Errors included wrong dose (seven), omitted dose (six), wrong drug (five), wrong site (two), and unnecessary drug (one). Causes included failure to consider weight-based dosing, use accurate drug references, calculate the total medication supply needed, verify the administration site, consider pertinent patient information (e.g., allergies), reconcile medications upon transfers, and document medication histories. Use of preprinted order forms was flawed, and discharge instructions were insufficient to guide patients postoperatively.

Failure to adhere to safe medication-use practices occurred throughout perioperative care. Improvement in medication documentation, following established safe practices, integration of patient information in prescribing decisions, and use of clinical decision support systems appear necessary to prevent perioperative medication errors in otolaryngology.
Received: 25 January 2010; Revised: 20 February 2010; Accepted: 25 February 2010