A Multi-Incident Analysis of Medication Error Reports Associated with Post-Anesthetic Recovery Areas in Hospitals

Incident Example: A patient who had both a gastrostomy tube (G-tube) and a jejunostomy tube (J-tube), required surgery. The pre-operative transfer of accountability conveyed to the OR team noted that the patient could only tolerate medications if given through the J-tube. In the PACU, medications were inadvertently ordered to be given through the G-tube. The PACU nurse was unaware of any previous instructions given to the OR team and administered the medications through the G-tube as specified. The patient aspirated the medications and went on to develop aspiration pneumonia.

Recommendations:

• Standardize the transfer of accountability process. Properly structured handovers (e.g., SBAR, I-PASS) support sharing of sufficient information to enable the transfer of accountability for a patient between health care providers.^9,10
• Ensure a mutual understanding of medications ordered and administered, and key monitoring parameters.
  • An evidence-informed checklist can support transitions of care in the perioperative period.¹¹
  • An electronic medical record-based handoff tool can help reduce the likelihood of miscommunication.¹²
• Consider adding visual alerts to help convey important information.
  • a label (or sticker) at the point of invasive line/tube access (e.g., G-tube for suction only)
  • a sign at the bedside (e.g., regional anesthesia)
• Invite patients and their care partners to ask questions and be active members of their care team.¹³

Incident Example: A patient appeared pale and unwell and was lethargic and hypotensive upon admission to the nursing unit following discharge from the PACU. After an urgent assessment, the patient required transfer to the intensive care unit where it was determined they were bleeding internally. Investigation identified that there had been some warning signs of patient instability in the PACU. It was also identified that a tranexamic acid IV infusion had been inadvertently stopped in the PACU.

Recommendations

• Ensure that patients meet organization-specific criteria for discharge from recovery areas before they are transferred to another care area.
  • If the patient does not meet the criteria for discharge from the recovery room, or there is uncertainty, the anesthesiologist and/or surgeon should be notified to reassess the patient.
  • Vital signs, pain assessment and dressing checks should be done just prior to transfer.
• During handover to the receiving unit, include information about medications given in the PACU/recovery room.
• Medication reconciliation, by the receiving unit, needs to integrate:
  • a review of post-operative orders written by the surgical team
  • a review of the pre-admission medication list
  • a check that medications ordered in the PACU/recovery but not yet given (due to timing of discharge) are ordered for administration in the receiving unit
• If discharging a patient home from a recovery area, review post-operative care instructions with the patient and/or family, including signs and symptoms that should be monitored.

Incident Example: An anesthesiologist administered a dose of phenylephrine to a patient with low blood pressure upon the patient’s arrival to the PACU, and ordered ephedrine 5 mg IV if needed. The patient’s blood pressure remained unstable, and the nurse mistakenly administered phenylephrine 5 mg, instead of the intended ephedrine. Additional monitoring and transfer of the patient to a close observation unit were required.

Recommendations

• Whenever possible, provide products in ready-to-use formats (e.g., prefilled syringes or prepared IV solutions).
• Consider integrating technology-based interventions (e.g., computerized physician order entry, point-of-care bar code scanning, and smart pump technology) which have built-in safeguards.¹⁶
• Implement independent double checks when administering IV push medications and when programming smart infusion pumps (e.g., to deliver patient-controlled analgesia and epidural infusions).¹⁷

Recommendations

• Standardize handover procedures, including communication of allergy status.
• Implement integrated and automated systems, such as those that exist in other areas of the hospital, to seamlessly communicate updated allergy information to all health care providers involved in a patient’s care.¹⁸

Incident Example: A nurse administered morphine to a patient using a syringe prepared by another nurse. The nurse assumed the syringe had been prepared from a 2 mg vial of morphine and determined the volume for injection accordingly. Later, it was determined that the syringe had been prepared using a 10 mg vial of morphine. The patient was inadvertently given 5 mg when the intended dose was 2 mg; there was no harm to the patient.

Recommendations

• Reassess workflow to minimize workarounds such as pre-pouring. If pre-pouring of medications is a regular occurrence, treat the situation as an opportunity to address underlying issues leading to this practice.¹⁹
  • A nurse should both prepare and administer medications needed only for their assigned patients.
  • For emergency situations, and in phase 1 recovery where more than one nurse is involved in the preparation and administration of medications, perform a double check by having one nurse prepare and label the medication and the other nurse independently verify the medication used and the dose before administering it.¹⁹

Incident Example: A preadmission medication list received by the PACU for an admitted patient was not scanned and sent to pharmacy as per hospital protocol. Post-operative orders did not include the patient’s regular medications. As a result, the electronic MAR was incomplete and doses of multiple medications were missed over a 24-hour period.

Recommendation

• Integrate records from perioperative areas into digital systems to reduce the risk of order omissions.