Preventing Postoperative Complications in the Elderly

Preventing Postoperative Complications in the Elderly

Medication Safety in the Perioperative Setting

George M. Hanna, MD, Wilton C. Levine, MD

Drug administration errors are a major cause of morbidity and mortality in hospitalized patients. These errors result in major harm and incur dramatic costs to the delivery of health care. This article highlights this problem, especially as it deals with patients in the perioperative setting.

Keywords: Medical errors, Medication errors, Perioperative safety

Article Outline

•

• The operating room milieu

• Types of medication errors

• Perioperative standards and regulations

• Standardization

• Technology

• Pharmacy

• Culture

• Solutions: techniques and technology

• Reporting errors: a new culture

• Summary

• References

• Copyright

In 1999, the Institute of Medicine (IOM) reported that between 44,000 and 98,000 patients die annually as a result of preventable medical errors. These medical errors include adverse drug events, incorrect transfusion therapy, wrong-site surgery, and others. The IOM also found that at least 1.5 million preventable medication errors cause harm in the United States each year.1 The IOM concluded that the most serious consequences of these errors occur in operating rooms, intensive care units, and emergency departments.1

Drug administration errors are a major cause of morbidity and mortality in hospitalized patients. These errors result in major harm and incur dramatic costs to the delivery of health care. In the United States, medication errors are estimated to cause approximately 7000 deaths per year.2 Preventable drug errors are projected to directly cost a 700-bed teaching hospital $2.8 million annually,3 based on postevent lengths of stay and total costs.

In health care, and especially in anesthesia, medication errors represent one of most prevalent contributors of iatrogenic injury.4 The discipline of anesthesiology involves the delivery of multiple potent drugs, often given in rapid succession during high-acuity situations. The specialty is unique, as it is responsible for the direct preparation, dosing, and delivery of medications to patients by a physician and anesthesiologist, certified registered nurse anesthetist (CRNA), or anesthesia assistant (AA). In a survey of 687 Canadian anesthesiologists, 85% reported a drug error or near miss in clinical practice.5 In a New Zealand study, 12.5% of practitioners surveyed reported that they were aware of causing harm to a patient because of a drug administration error.4

The operating room milieu 

The operating room is a distinct environment with a rapid workflow requiring immediate decisions and decision support. Research from the aviation industry indicates that errors occur more frequently in hectic, demanding and fast-paced environments,6 such as the operating room. Best practice methods from elsewhere in the hospital, however, are not readily transferable and applicable to this setting. Despite persistent education and best efforts, errors continue to occur in the perioperative environment.

In most hospital areas, the typical workflow for medication administration to a patient involves important and time-consuming checks and balances (Fig. 1A). In this process, a physician first writes an order for a particular medication for a specific patient. A pharmacist then evaluates the order as it relates to the specific patient for appropriate dose, indication, patient allergy, and potential contraindications. The pharmacist next either approves the order or clarifies any questions. A nurse is next able to review the medication order in the hospital order entry system. If the medication is stocked on the patient floor, the nurse may obtain access to the medication after this approval process; otherwise a pharmacist must dispense the medication to the patient location. Before administration of the medication to the patient, the nurse reviews the five medication rights: right patient, right time and frequency of administration, right dose, right route of administration and right drug. After completing all of these steps, the nurse administers the medication to the patient. Not surprisingly, this process can take hours to employ, with several checkpoints and hard stops before a subsequent step in the process is undertaken.

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Fig. 1 (A) Typical process for medication administration in the hospital. (B) Typical process for medication administration in the operating room.

In the operating room, the process is dramatically abbreviated. The anesthetist internally writes an order, approves an order, prepares the medication, and administers the medication to a patient. This practice often takes seconds, and lacks the safeguards that exist in other areas of the hospital (see Fig. 1B).

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PULMONARY ARTERY PRESSURE MONITORING

PULMONARY ARTERY PRESSURE MONITORING

Pulmonary artery pressure monitoring is measuring the pressure in the pulmonary artery leading to the lungs. It also allows for indirect measurement of left heart pressures since the pulmonary veins have no valves in them and collects the information needed to calculate cardiac output and resistance. The PA catheter assesses all 3 components of stroke volume: preload, afterload, and contractility.

The catheter is 60-100 cm long and the caliber is 4-8 Fr (a standard suction catheter is 14 French)...the balloon will hold 0.5-1.5 ml of air and get 8-13 mm big when inflated
Distal Port:
• terminates in the pulmonary artery
• used to monitor pulmonary artery pressure and pulmonary capillary wedge pressure when the balloon is inflated
• provides a port for mixed venous blood samples
Balloon Inflation Port:
• used to inflate the balloon at the end of the PA catheter with no more than 1.5 ml of air
• has a locking device for safety
• is inflated during insertion to allow the catheter to float into correct position
• when inflated will measure pulmonary capillary wedge pressure, which is equal to the pressure in the left atrium and ventricle during diastole

Proximal Injectate Port:
• is usually blue in color
• provides a port for injecting fluid when measuring CO
• measures RA/CVP
• can be used as an IV infusion site if CVP monitoring not needed
Proximal Infusion Port:
• is usually white in color and AKA venous infusion port
• lumen opens into the RA
• can be used to infuse fluids or meds without interruption
• is not attached to the transducer

Cardiac Output Port:
• a white square port with pins that connects to the CO cable
• the CO cable connects to the monitor
• has temperature sensitive wires that terminate near the distal tip

• is used for thermodilution CO measurement

Other Ports:
• Pace Port for a ventricular or atrial pacemaker
• SvO2 monitoring port

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