Patient Safety Tip of the Week
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
Many
have asked why all Joint Commission’s patient safety goals should apply to
ambulatory surgery sites. After all, the patient is only there for a matter of
hours and then goes home. Right? Why should we have to jump through all sorts
of hoops for something that really doesn’t pertain to us? We are only here to
do this one procedure and what do we know, anyway, about all those other
medical problems the patient has.
Well,
you have to remember that ambulatory surgery is a part of a larger healthcare
continuum and events related to ambulatory surgery can be reflected in other
parts of that continuum. Let’s look at an example. Last week we mentioned that
medical records are often a problem in ambulatory surgery sites. A patient came
to an ambulatory surgery site for a procedure. Very little history had been
provided prior to the patient’s arrival so on the day of the procedure staff
asked the physician’s office to fax over some relevant office notes and the
medication sheet. While hospitals have clearly begun to comply with the “do not
use” abbreviation lists, most physician office notes are still replete with
such abbreviations. The faxed notes were included in the facility medical
record. The surgical procedure went well and the patient went home without
incident or complication. However, 2 weeks later she was seen in the ER of the
same hospital system for an unrelated problem. The patient’s primary physician
was not available. The ER physician found in the patient chart copies of those
office records that had been faxed in to the ambulatory surgery site. One of
the medications listed in those records had a “qd” abbreviation that, perhaps
in part because of fax artifact, looked like “qid”. The patient was admitted
from the ER to the hospital and her maintenance medication that had been
intended to be given once daily was now actually give four times daily. The
error was not discovered until the patient developed symptoms of drug toxicity
5 days later. Well-performed medication reconciliation and compliance with the
“do not use” list goal could have prevented this adverse outcome. But the case
nicely illustrates how events in one part of the system can effect events in
another part.
Medication
reconciliation is also critical before and after ambulatory surgery. It is
critical that a full list of the patient’s medications, including OTC drugs and
herbal remedies, be reviewed before the procedure. Several of these might
predispose the patient to bleeding problems, for example. And one especially
needs to know when the last dose of medication prior to arrival for the
procedure was taken. This is especially relevant for medications such as
insulin and ties together with orders for the patient to be “nothing by mouth”
for a period prior to surgery. Similarly, it can be anticipated that on
discharge from ambulatory surgery the patient is likely to receive some new
drugs, for example analgesics and perhaps and antiemetic. One needs to be sure
there is not likely to be a drug-drug interaction with the patient’s current
medications.
Last
week we noted that 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). Today’s tip illustrates why at least 2 of those
goals are important in ambulatory surgery patient safety. We’ll talk about
labeling medications and solutions and look-alike/sound-alike drugs in future
tips.
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Safety Tip of the Week Archive