Perioperative medication errors in otolaryngology.

Area of Science:

• Medical Safety
• Surgical Outcomes
• Pharmacology

Background:

• Medication errors are a significant contributor to adverse clinical outcomes.
• Data on medication errors specifically within the perioperative period, particularly in otolaryngology, is limited.

Purpose of the Study:

• To identify the types, causes, and potential solutions for medication errors in otolaryngologic surgery.
• To assess the prevalence and nature of medication errors from the preoperative phase through the initial postoperative clinic visit.

Main Methods:

• A prospective, descriptive study design was employed.
• Clinicians were encouraged to report medication errors over a two-month period.
• An expert panel reviewed reported errors to determine validity, preventability, and contributing factors, with concurrent monitoring of safe medication practices.

Main Results:

• Twenty medication errors were reported across 589 surgeries, occurring in preoperative, operative, inpatient, transfer, discharge, and postoperative stages.
• Common errors included wrong dose (seven), omitted dose (six), and wrong drug (five).
• Identified causes involved issues with weight-based dosing, drug references, medication reconciliation, documentation, and insufficient discharge instructions.

Conclusions:

• Adherence to safe medication use practices was suboptimal throughout the perioperative care continuum in otolaryngology.
• Enhancements in medication documentation, consistent application of safe practices, incorporating patient-specific information, and utilizing clinical decision support systems are crucial for error prevention.