USP report details extent of surgery medication errors

From the holding area to the recovery room, drug mistakes in surgery are common and can cost lives. Experts call for more pharmacist involvement.

By Kevin B. O'Reilly, AMNews staff. March 26, 2007.

For an outpatient surgical procedure on an elderly female patient, the physician gave a verbal order for 100 mcg fentanyl and 1 mg midazolam. The nurse confirmed the order but incorrectly administered the drugs. After 11 minutes, the patient was unresponsive and a team rushed to save her life with naloxone and supplemental oxygen.

This was just one of more than 11,000 surgical medication errors that 870-plus hospitals reported to U.S. Pharmacopeia's Medmarx database between 1998 and 2005. In this case, the improper dose of fentanyl due to a misunderstood verbal order nearly cost the patient her life. In about 5% of the errors, the wrong drug, wrong dose, wrong time, wrong administration, or omission of drug caused direct harm to the patient and, in four cases, contributed to or directly caused patient deaths.

According to USP's March report, medication errors occur in all the clinical areas involved in perioperative care: outpatient surgery, the holding area, the operating room and the recovery room. Communication errors, failure to follow procedures and protocols, and inadequate documentation were some of the most frequently reported causes of errors.

While nurses were identified the majority of the time as being directly involved with the error, physicians were the second most likely to be so identified. The drugs most frequently involved with errors, though also the most widely used in surgery, were antibiotics and painkillers.

Experts said that because the USP report relies on voluntarily reported data, it is likely to underestimate the extent of medication errors, as well as how frequently they cause harm.