PSA Advisories

Perioperative Medication Errors: Uncovering Risk from Behind the Drapes

Medication use in the perioperative setting presents unique patient safety challenges compared with other hospital settings. For example, perioperative medication prescribing and administration often bypasses standard safety checks, such as electronic physician order entry with decision support, pharmacy verification of specific drugs before administration, and multiple nursing checks at the time of medication administration. A total of 1,137 medication error events associated with the perioperative settings (e.g., operating room, anesthesia, postanesthesia care unit) were identified by analysts in event reports to the Pennsylvania Patient Safety Authority that occurred during calendar year 2017. More than half (54.6%, n = 621) of reported events reached the patient. Nearly three-quarters (74.9%, n = 852) of events were attributed to a breakdown in the communication process during transitions of care or handoff procedures. Other common contributing factors involved problems with the medication ordering process, as well as improper handling of medications leading to mix-ups and accidental administration of high-alert medications. Organizations may use this data to inform proactive efforts to standardize protocols in the perioperative setting and prevent similar errors from occurring.

Please click here for the complete article on the Pennsylvania Patient Safety Authority’s website.

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