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    Low-Tech Solutions Can Reduce Medication Errors

    By Jennifer Huddleston, staff writer     

    Anesthesiologists, residents and nurses at Penn State Hershey in Hershey, Pennsylvania, tested a simple color-coded system while simulating emergency room situations, and found that standardizing the appearance of drug labels could reduce the number of medication errors in emergency rooms and operating rooms (ORs). [1]

    About 1.5 million adverse drug reactions are caused by medication errors each year and these drug errors cost the healthcare industry approximately $3.5 billion annually.
    [2]

    Eric Chernin, RPh, BSPharm, a pharmaceutical specialist in Sarasota Memorial Hospital’s OR pharmacy in Sarasota, Florida, said a high rate of medication errors is unsurprising when you consider the more than 40 separate steps required to administer a drug in the OR.
    [3]

    The Penn State Hershey study found that when the color of the label on the syringe matched the color of the label on the medication bottle, fewer mistakes were made than when the colors didn’t match. Further, when peel-off labels were taken from the medication bottle and placed on the designated syringe, the number of commands skipped and the total number of errors were reduced.
    [4]

    According to 1998-2005 data submitted to MEDMARX, the United States Pharmacopeia’s voluntary drug error reporting system, more than 3,500 OR medication errors were reported, 7.2 percent of which caused harm to patients. In preoperative areas, however, just less than 800 errors were reported, 2.8 percent of which harmed patients.
    [5]

    Chernin cites several factors that contribute to these errors, including a lack of training of OR staff, frequent staff and shift changes, a lack of pharmacy involvement, a fast-paced environment, use of verbal drug orders, poor drug labeling and fatigue.
    [6]

    According to MEDMARX data on drug errors submitted between 1998-2002, anesthesiologists were responsible for 7.3 percent of the reported errors, while registered nurses (RNs) were responsible for more than half (54 percent).
    [7]

    “It is interesting that RNs were found to be responsible for so many drug errors, despite the fact that they don’t actually administer many meds in the OR,” Chernin said. “This underscores the fact that there are multiple sources of potential medication errors in the OR—nurses, pharmacists and other caregivers all play a role. All of these groups need to work together and address the causes of errors, such as verbal drug orders and improper drug labeling, if we are to maximize patient safety.”
    [8]

    According to the Institute of Medicine, hospital patients experience one drug administration error each day and these types of errors account for 26-32 percent of all adult patient medication errors.
    [9]

    Together, anesthesiologists and other OR clinicians can help reduce the number of drug errors by employing tactics such as discontinuing verbal medication orders and the use of unlabeled drugs.
    [10]

    “Many ‘high-tech’ solutions have been suggested, including the use of bar codes, radiofrequency identification for medications and computerized medication administration processes,” said Elizabeth H. Sinz, M.D., part of the anesthesiology department at Penn State Hershey and researcher in the color-coded study. “But besides their high costs, all of these methods have flaws that may produce as many errors as they eliminate. Furthermore, these solutions are often impractical for fast-paced situations in operating rooms or during emergencies.”
    [11]

    Problems with high-tech solutions include unreadable medication barcodes, faulty scanners, unreadable or missing patient ID wristbands, medications without barcodes and lost wireless connectivity.
    [12]

    Good communication during drug handling, accurate drug labeling and awareness of drugs that look and/or sound alike are a few of the strategies for promoting safe medication use, part of The Joint Commission’s National Patient Safety Goals. Chernin suggested using various manufacturers, vial sizes and color-coded stickers or labels to distinguish drugs that are often mistaken for others.
    [13]

    “Simple systems, such as the color-coding methods used in our study, are more reliable and useable than complex systems,” Sinz said.
    [14]


    [1] McKeever, Kevin. “Study Urges Low-Tech Solutions for Medical Errors.” MedlinePlus. Oct. 19, 2008.
    [2]  Ibid.
    [3] Tilyou, Sarah. “A Prescription for Improving Medication Safety in the OR.” Anesthesiology News. November 2008.
    [4] McKeever, Kevin. “Study Urges Low-Tech Solutions for Medical Errors.” MedlinePlus. Oct. 19, 2008.
    [5] Tilyou, Sarah. “A Prescription for Improving Medication Safety in the OR.” Anesthesiology News. November 2008.
    [6]  Ibid.
    [7]  Ibid.
    [8]  Ibid.
    [9] “Study: Low-Tech Solutions Might Minimize Medical Errors.” NewsInferno.com. Oct. 21, 2008.
    [10] Tilyou, Sarah. “A Prescription for Improving Medication Safety in the OR.” Anesthesiology News. November 2008.
    [11] McKeever, Kevin. “Study Urges Low-Tech Solutions for Medical Errors.” MedlinePlus. Oct. 19, 2008.
    [12] “Study: Low-Tech Solutions Might Minimize Medical Errors.” NewsInferno.com. Oct. 21, 2008.
    [13] Tilyou, Sarah. “A Prescription for Improving Medication Safety in the OR.” Anesthesiology News. November 2008.
    [14] McKeever, Kevin. “Study Urges Low-Tech Solutions for Medical Errors.” MedlinePlus. Oct. 19, 2008. 


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