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Harmful errors most likely in perioperative setting
Some 12% of pediatric med errors result in harm
A study released by the United States Pharmacopeia (USP) says perioperative patients face an increased risk of harmful medication errors throughout the surgery process due to a lack of comprehensive oversight of medications. The seventh annual national Medmarx Data Report released by the USP studied medication errors in the perioperative setting — including outpatient surgery, the preoperative holding area, the operating room, and the post-anesthesia care unit.
The Medmarx report looked at more than 11,000 medication errors in the perioperative setting and found that 5% of the errors resulted in harm, including four deaths. USP says this percentage of harm is more than three times higher than the percentage of harm among all Medmarx records. Children are at higher risk for harm in the perioperative setting, with nearly 12% of pediatric medication errors resulting in harm.
According to USP, what many people generally call "surgery" is actually a system of several different departments that patients move through to receive perioperative care, and each department is likely to have different teams of healthcare providers. "Even if located along a single hallway, these departments can be remarkably disconnected from one another," said USP Healthcare Quality Information vice president Diane Cousins, one of the report's authors. "The fragmented system creates a high risk for harmful medication errors."
The highest rate of harmful medication errors occurred in the operating room (7.3%). The post-anesthesia care unit had the next highest rate at 5.8%, followed by the outpatient surgery department at 3.3%, and the perioperative holding area at 2.8%.
To improve patient safety and reduce the risk of medication errors, USP recommends that hospitals and health systems dedicate pharmacists to the perioperative units so they can oversee the distribution of medications and that surgical staff better coordinate hand-offs.
Meanwhile, a special California Medication Errors Panel that spent a year taking testimony from experts in the field of medication errors says such errors are estimated to injure or kill 150,000 Californians each year and contribute to costs of more than $17 billion.
The in-depth report from the panel that was appointed by the legislature focuses on the causes of medication errors in the outpatient setting and recommends changing the healthcare system to protect consumers from errors associated with use of prescription and OTC medications.
"Not enough has been done in California to address this critical issue," said former state Sen. Jackie Speier, who introduced the legislation creating the panel. "The recommendations of the panel will save the lives of thousands of Californians and should be incorporated into legislation without delay."
In hearing from 32 invited speakers, the panel learned that:
The panel report contains 12 consensus recommendations for systemic change. Those recommendations are:
[Editor's note: More information on the USP report is available online at http://www.usp.org. The California report is available online at http://www.pharmacyfoundation.org/medicationerrors.]