Best practices for safe medication administration.

Recently, an inadvertent injection of chlorhexidine during a radiological procedure led to the tragic death of a 69-year-old grandmother named Mary McClinton. (1) This death, the result of system errors, may have been preventable. Unfortunately, it follows a number of other patient deaths that occurred as the direct result of solutions being placed in unlabeled basins during surgical and other invasive procedures. (2)

Three years ago, Ben Kolb's parents' appeared on a nationally televised show and told the story about their seven-year-old son inadvertently being given epinephrine 1:1,000 as a local anesthetic instead of the intended lidocaine with epinephrine--a fatal error. (3) After the story aired, many individuals throughout the country who are involved in health care took action to prevent similar errors. AORN developed and disseminated its first guidance statement regarding safe medication practices in perioperative practice settings and launched the Patient Safety First initiative. Many individuals wrote articles and columns related to medication safety in perioperative settings, and a variety of speakers gave presentations on the topic.

Despite these efforts, patient deaths due to medication labeling errors still occur. Placing liquids in unlabeled containers led to the patient deaths described above, and similar situations continue to occur in some health care organizations and clinical settings. Furthermore, when health care providers began performing invasive procedures in diagnostic and interventional settings rather than in the OR, personnel caring for those patients may not have been aware of practices that traditionally had ensured safety in perioperative settings. This lack of knowledge, coupled with the fast pace of many interventional and diagnostic departments, contributes to the potential for errors to occur. What seems like a harmless activity (eg, not labeling liquids in sterile basins) can easily lead to disaster.

BEST PRACTICES

Resources for best practices for medication safety in perioperative settings do exist. The Institute for Safe Medication Practices provides a variety of resources, including a monthly newsletter that devoted an entire issue to this topic. (2) AORN has resources related to medication safety, including the AORN guidance statement, "Safe medication practices in perioperative practice settings." (4) The statement contains details about risk reduction strategies and a sample protocol for safe medication handling and administration in the OR. These include labeling all medications in sterile basins--even when there is only one basin or one medication or liquid on the sterile field. Labels should include the name and strength of the medication. Additionally, all labels should be verified verbally. The name of the medication, as well as its strength and dosage, should be stated and verified visually and concurrently by the scrub person and the circulating nurse. (4)

AORN also recently introduced its Safe Medication Administration Toolkit. The toolkit includes

* medication administration competencies;

* common medication conversion calculations;

* a herbal interactions poster;

* a pocket reference of common perioperative medications; and

* contact hour modules covering medication errors, perioperative pharmaceutical considerations, and medications common to perioperative patient care. (5)

Information on best practices must be disseminated in all settings where surgical, invasive, or diagnostic procedures are performed. To achieve this goal, perioperative nurses must be willing to share their expertise with ancillary departments. For example, perioperative nurses need to share their knowledge on how to set up a sterile field, how to prepare for a surgical emergency, and how to ensure surgical asepsis. Sharing expertise establishes the perioperative nurse's role in setting and maintaining best practices. Without the help and guidance of experienced perioperative nurses, individuals with less expertise and knowledge may lack the requisite knowledge to provide safe care.

THE POWER OF SHARED KNOWLEDGE

By sharing their knowledge, perioperative nurses become valued resources for their coworkers. AORN members also can share AORN resources with nonmembers and clinicians outside of traditional surgical settings. For example, many departments (eg, cardiac catheterization, electrophysiology, interventional radiology departments) are unaware of resources such as AORN's recommended practices and educational opportunities relating to best practices for invasive procedures. Sharing these resources can provide nurses in interventional departments with valuable clinical information about providing high-quality care in their practice settings.

Perioperative nurses must extend their practice beyond the four walls of the OR suite. In doing so, they can influence clinical care across the care continuum. Their knowledge and expertise can help other nurses establish and provide a comparable standard of care across settings. Perioperative nurses' knowledge serves as an invaluable resource in a variety of clinical settings, especially those outside the OR.

AN OUNCE OF PREVENTION

When knowledge about safe practices is shared across settings, lessons learned from an error can help others recognize error conditions and prevent similar errors. For example, the principles related to identifying patient, site, and laterality affect numerous settings, including interventional radiology, obstetrics, outpatient settings, and ambulatory surgery departments. Perioperative nurses cannot work in isolation when establishing best practices; they must work with their colleagues in other departments.

Being alert to conditions that may cause errors is every clinician's responsibility. Detecting conditions under which errors may occur and taking steps to minimize risks are essential components of the nurse's role. Becoming familiar with best practices for safe medication administration and sharing them with colleagues in all pertinent areas of the health care arena are two vital first steps in preventing potentially tragic medication errors.

NOTES

(1.) L Byron, "Investigators: Medical Mistake Kills Everett Woman," King5.com, News for Seattle, 23 Nov 2004, http://www.king5.com/localnews/investigators /stories/NW_112304WABhospitalinjectspatientJK.878fe03c.html (accessed 8 Feb 2005).

(2.) "Loud wake-up call: Unlabeled containers lead to patient's death," Institute for Safe Medication Practices, http://www.ismp.org/msaarticles/loudprint.htm (accessed 10 Feb 2005).

(3.) E Cohen, "Medical groups release new safety recommendations, questionnaires," CNN.com Health, 19 May 2000, http://archives.cnn.com/2000 /HEALTH/05/19/hospital.errors/ (accessed 8 Feb 2005).

(4.) "AORN guidance statement: Safe medication practices in perioperative practice settings," in AORN Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005).

(5.) Safe Medication Administration Toolkit (Denver: AORN, Inc, 2005).

RESOURCE

AORN's Safe Medication Administration Toolkit

AORN introduced its Safe Medication Administration Toolkit at the 52nd Annual AORN Congress in New Orleans, April 3 to 7, 2005. The tool kit was initiated by the AORN Presidential Commission on Patient Safety and the Workplace Safety Task Force. Created as both a teaching tool and resource package, the toolkit is intended to assist perioperative nurses in advocating for safer patient care with components highlighting

* medication administration competencies,

* common medication conversion calculations,

* herbal interactions,

* common perioperative medications,

* medication errors,

* perioperative pharmaceutical considerations, and

* medications common to perioperative patient care.