Multidisciplinary approach to improving documentation of medications used during surgical procedures

A multidisplinary approach to improving medication documentation in the operating room (OR) of a 350-bed teaching hospital is described. A committee composed of the OR pharmacy supervisor, the assistant director of nursing in charge of the ORs, and a review coordinator from the auditing department developed a medication accountability system for the OR. The system consisted of a medication use record created by the pharmacy member of the committee for each of the hospital's two ORs (main OR and eye and ear infirmary OR). The nonsterile nurse in each OR suite would complete these forms by placing check marks next to the names of the medications used. A separate medication use record was created by the chief perfusionist for use in cardiopulmonary bypass cases; this form would be completed by the perfusionist at the end of each major heart case. Once the forms were approved by the form committee, inservice-education programs were conducted for nursing and perfusion staff members; the system was implemented in both OR areas in November 1986. Errors made in completing these forms were addressed by further inservice education and individual instruction. The new accountability system was effective in improving medication documentation in the OR. Immediately after implementation of the system, 83% of medications were accounted for on the forms; after six months that figure was 90%. Before the system was implemented, only 23% of patient charts reviewed contained no errors in documentation; after six months that figure had improved to 71%. The improved medication documentation allowed for more consistent collection of the assessed pharmacy charges on bills audited by third-party payers.(ABSTRACT TRUNCATED AT 250 WORDS)