A lack of comprehensive oversight and a fragmented system increase the risk of medication errors throughout the surgery process, according to a report released this week by the U.S. Pharmacopeia Center for the Advancement of Patient Safety. The report did not include a strong recommendation for technological solutions to the problem.
Using USPs Medmarx software, which is an anonymous, Internet-accessible program, researchers analyzed more than 11,000 medication errors that occurred between 1998 and 2005 at 590 facilities across the surgery "continuum." These settings included outpatient surgery, preoperative holding areas, operating rooms and post-anesthesia-care units. They found that 5% of these errors resulted in patient harm, with four errors being fatal. Nearly 12% of pediatric medication errors in these settings resulted in harm.
Use of computerized prescriber order-entry systems may not be that helpful in reducing errors in the outpatient setting, the report said, because the CPOE system might not be connected or affiliated with the hospital e-prescribing system, radiology department or laboratory that dealt with the patient, so it would not necessarily have access to relevant information needed to avoid errors."These common issues in outpatient care hinder the ability of the technology to work effectively in this environment," the report said. "Even if the best technology is available in the physicians' offices, laboratories, radiology centers and (outpatient settings), there is a lack of integration among these settings."
The report recommends that more research is needed to investigate how CPOE and electronic health records can be used to specifically lower medication errors in the surgery continuum.
The strongest endorsement of using technology was in the post-anesthesia-care units, where researchers found medication errors in 11% of the sample casesincluding two which required life-saving interventionsand concluded that they were all preventable and suggested using automated dispensing devices and bar-coding systems to lower the risk of error.