Patient Safety Tip of the Week
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
In our June 5, 2007 and June 12,
2007 Tip of the Week columns we discussed medication-related patient safety
issues in ambulatory surgery settings. Joint Commission is finding less than
full compliance in ambulatory surgery
on several medication-related goals (eg. medication reconciliation, labeling
medications and solutions, “do not use” abbreviations, and
look-alike/sound-alike drugs).
The April 2007 issue of USP Patient Safety CAPSLink™ examined
medication errors in outpatient surgery, based on data collected from the
MEDMARX reporting system. For adult patients, nearly 70% of the medication
errors in ambulatory surgery were in the administration phase. They point out
that many of the drugs in ambulatory surgery units are not prepared or reviewed
by pharmacists, thereby omitting a potential patient safety defense. They also
note, as we previously did, some of the issues around inadequate medical
records, time pressures, etc. that are more frequent in the ambulatory surgery
setting. Computerized physician order entry (CPOE), a tool with great potential
for reducing medication errors, is seldom available to or used by physicians in
the ambulatory surgery setting. The article provides several recommendations
for reducing outpatient surgery medication errors.
Look-alike/sound-alike (LASA)
medication errors continue to be a problem in all healthcare settings and
ambulatory surgery is no exception. Lists of problem-prone LASA drug name pairs
are available through Joint Commission and ISMP . ISMP’s August 9, 2007 Acute Care Newsletter has a good discussion about name
confusion errors. It highlights some of the actitivies ongoing to reduce
problems related to drug name confusion and notes an upcoming summit on the
issue. It provides several practical steps that healthcare facilities may take
to minimize the risk of LASA medication errors. The FDA also has had a Name Differentiation Project that encouraged
drug manufacturers to use “tall man” letters in their labeling of certain
drugs. And one of the 9 Patient Safety Solutions recently published by the WHO Collaborating Centre for Patient Safety focuses
on LASA Medication names. The latter is well-referenced and highlights barriers
and possible uninteneded consequences along with many practical
recommendations.
Each facility should have a list of
targeted name pairs it will focus on and have a mechanism by which it will
revise/update the list and disseminate the information and education to all
members involved in ambulatory surgery activities. Examples of drug name pairs
that might be encountered more frequently in ambulatory surgery might be:
Amicar/Omacor, Darvon/Diovan, Anzemet/Avandamet, Celebrex/Celexa,
Diprivan/Ditropan, ephedrine/epinephrine, fentanyl/sufentanil, Foradil/Toradol,
heparin/Hespan, hydromorphone/morphine, Inderal/Adderal, Ketalar/ketorolac,
Lasix/Luvox, MS Contin/oxycontin, Narcan/Norcuron, Paxil/Plavix,
tizanidine/tiagabine, Zantac/Zyrtec.
Use of CPOE (with special alerts
for potential LASA issues) or preprinted orders may be helpful. Requiring use
of both the brand name and generic name when prescribing may also be
helpful but is difficult to implement and sometimes has the unintended
consequence of introducing additional errors.
Requiring the indication for any
ordered medication may help prevent a LASA error. In addition to the dosage
form, drug strength, route of administration, and complete directions, knowing
what use the drug is intended for may help a nurse or pharmacist avoid a LASA
error.
Use of “Tall Man” letters for LASA
pairs on labels or on computer screens, etc., has been suggested as a solution.
Examples of “Tall Man” lettering are: VinBLAStine/VinCRIStine or
HydrALAZINE/HydrOXYzine. USP is conducting a survey of provider organizations
to see the impact of “Tall Man” lettering on medication safety. Other
techniques to highlight potential LASA-risk might include flagging with color,
boldface, “name alert” stickers, etc. (but beware there is no current color
standard for LASA drugs). Separate storage of one of a LASA drug pair in a
different part of the pharmacy/facility may be useful (but beware of unintended
consequences). Automated dispensing devices may be especially problematic when
it comes to LASA drug pairs, particularly when more than one drug is stored in
the same compartment. Some of the newer devices allow for programming alerts
that might alert a nurse of a potential LASA drug.
Involving a pharmacist in the
process is a very important step that few ambulatory surgery sites currently
utilize. And other more general practices, such as avoiding verbal orders,
remain very important in avoiding LASA errors.
And formulary management is
important. LASA issues should be considered any time a new drug is being
considered for addition to the formulary. Another consideration is stocking
different strengths of a potential LASA pair (eg. don’t stock 2 mg/ml strengths
for both drugs).
Most importantly, monitor the
practices in your facility as part of your QI activities. Just as you monitor
for unacceptable abbreviations, or use of high-alert medications, you should
monitor for use of the LASA risk drug pairs you’ve chosen on your list. And,
obviously, encourage reporting of any new events or drug pairs that arise.
By the way, ISMP has updated its list of high-alert medications so as you
put together your LASA list, you might review/revise your high-alert medication
list, too.
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