Medication Safety during Anesthesia and the Perioperative Period

Description

With medication errors in healthcare an internationally recognised problem, this much-needed book delivers a comprehensive approach to understanding medication safety in the perioperative period. It reviews what medication adverse events are, and how often and where these errors occur, as well as exploring human cognitive psychology and explaining why things can go wrong at any time in a complex system. Detailed discussions around mistakes, judgement errors, slips and lapses, and violations, are presented alongside real-life examples of the indistinct line between negligence and inevitable error. The co-authors bring a wide and practical perspective to the theories and interventions that are available to improve medication safety, including legal and regulatory actions that further or impede safety. Essential reading for anesthesiologists, nurses, pharmacists and other perioperative team members committed to improving medication safety for their patients, and also an invaluable resource for those who fund, manage and regulate healthcare. Half title Title page Copyright information Dedication Contents Foreword Acknowledgments 1. Introduction to Medication Safety in Anesthesia and the Perioperative Period 1.1 Introduction 1.2 A Road Map to the Book 1.3 Some Definitions and Concepts 1.3.1 Definitions of Medication Error 1.4 Levels of Harm from Medication Errors 1.5 Measurement and Medication Safety in Anesthesia and the Perioperative Period 1.5.1 Early Days of Measuring Harm Associated with Anesthesia 1.5.2 Metrics for Measuring the Rate of Medication Errors 1.5.3 Incident Reporting in the Study of Medication Errors 1.5.4 Observational Studies of Medication Safety 1.5.5 Chart Review and Medication Errors 1.5.6 Simulation-Based Studies of Medication Safety 1.6 Conclusions References 2. Failures in Medication Safety during Anesthesia and the Perioperative Period 2.1 Introduction 2.2 Managing Medications during Surgical Patients’ Transitions of Care 2.2.1 Transitions of Care between the Community and the Hospital 2.2.2 Some Challenges to Medication Safety in the Presurgical Period 2.2.3 Reconciliation of Medications at the Preoperative Clinic 2.2.4 Medication Management for Outpatient or Same-Day Surgery 2.2.5 Medication Management for Surgical Patients Admitted to Hospital for One or More Nights 2.2.6 Transfers of Care Within the Hospital 2.2.7 Discharge from Hospital to Home 2.3 Failures in Medication Safety in the Operating Room 2.3.1 Rate of Medication Errors and Other Failures in Medication Safety during Anesthesia 2.3.2 Documentation Errors and Medication Safety 2.3.3 The “True” Rate of Medication Error during Anesthesia 2.3.4 The “Rights” of Safe Medication Management and Classifications of Failures to Achieve These 2.3.5 Failures in Aseptic Technique during Anesthesia 2.3.6 Harm from Failures in Medication Management during Anesthesia 2.3.7 Closed Claims Databases 2.3.8 Medication Errors by and between Different Members of the Operating Room Team 2.3.9 Contributory Causes to Failures in Medication Safety in the Operating Room 2.4 Failures in Medication Safety in the Postanesthesia Care Unit 2.5 Conclusions References 3. Failures in Medication Safety in the Intensive Care Unit and Ward 3.1 Introduction 3.2 Intensive Care Unit versus Ward Errors 3.3 Prescribing Errors 3.3.1 Contributing Causes and Factors for Prescription Errors 3.4 Dispensing Errors 3.5 Administration Errors 3.5.1 Preparation 3.5.2 Factors Contributing to Administration Errors 3.6 Conclusions References 4. Impact of Medication Errors on the Patient and Family: Managing the Aftermath 4.1 Introduction 4.2 Long-Term Impact 4.3 Our Sacred Promise Is “First, Do Not Harm” but When We Do, What Is the Next Promise? 4.4 Disclosure and Compassion 4.5 Conclusions References 5. Consequences for the Practitioner 5.1 Introduction 5.2 The Concept of the “Second Victim” 5.3 The Emotional Aftermath of Adverse Events 5.3.1 Traumatic Events in Everyday Life 5.3.2 Post-traumatic Stress Disorder and Psychological First Aid 5.3.3 Harming Instead of Helping 5.4 Blame and the Question of Negligence 5.5 The Impact of Avoidable Adverse Medication Events on Practitioners 5.5.1 Emotional Impact 5.5.2 The Risk of Suicide 5.5.3 The Impact of Conversations or Writing about an Adverse Event 5.5.4 Legal and Regulatory Consequences 5.5.5 Impact on Clinical Competence 5.5.5.1 Should Error-Prone Practitioners Stop Practicing? 5.5.6 Impact on Career and Reputation 5.6 Caring for Practitioners 5.6.1 What Is Done Today 5.6.1.1 The Resilience in Stressful Events Program 5.7 Conclusions References 6. Why Failures Occur in the Safe Management of Medications 6.1 Introduction 6.1.1 Two Cases of Poisoned Gas 6.1.2 The Role of the System in the Safe Administration of Medications 6.2 Medication Management and Types of Work 6.3 Complexity 6.3.1 The Inevitability of Accidents in Complex Systems 6.3.2 The Management of Perioperative Medications as a Complex Process 6.3.3 Design and Administration of Medications 6.3.4 Interrelationships, Society, the Human Factor, and Complexity 6.4 Mental Models and Hierarchies of Wisdom 6.4.1 How We Perceive the World: Schemata, Frames, and Mental Models 6.4.2 Personal Knowledge: Data, Information, Evidence, Knowledge, Wisdom, and Enlightenment 6.5 Assembling the Facts to Form a “Knowledge Base” 6.5.1 Accessing, Interpreting, and Storing the Facts 6.5.1.1 Information Overload: The Need to Filter, Find, and Verify 6.5.1.2 Changing Situations 6.5.1.3 Incorrect or Missing Information 6.5.1.4 Labels and Cognition: Size, Shape, Color, and Sound 6.5.1.5 Storing the Facts: Memory 6.5.2 The Sixth Sense and Situational Awareness 6.5.2.1 Déjà vu: Friend or Foe? 6.5.2.2 Prejudice and Bias 6.5.3 Expertise 6.6 Conclusions References 7. Errors in the Context of the Perioperative Administration of Medications 7.1 Introduction 7.1.1 Dopamine Strikes Again: A Failure to Learn from History 7.1.2 Making Medical Errors into Medical Treasures 7.2 Definition of Error 7.2.1 Element 1: Errors Are Unintentional but Reflect an Intention 7.2.2 Element 2: A Decision or Act Should not Be Judged by Its Outcome 7.2.3 Definitions of Medication Errors and Adverse Medication Events 7.3 Decisions and Actions 7.3.1 Fast and Slow Thinking 7.3.2 Classifying Failures in the Management of Perioperative Medications 7.4 Mistakes 7.4.1 System I Decisions and Mistakes 7.4.2 System II Decisions and Mistakes 7.4.3 Mistakes More Generally 7.4.4 Judgment and Uncertainty in Decisions 7.4.5 More on Mental Models 7.4.5.1 Shared Mental Models 7.5 Skill-Based Errors 7.6 Technical Errors 7.7 Humans, System Complexity, and the Predictability of Error 7.8 A New Framework for Classifying Medication Errors 7.9 Conclusions References 8. Violations and Medication Safety 8.1 Definition of a Violation 8.2 Risk, Violations, and Mental Models 8.2.1 Not All Violations Are Equal 8.2.1.1 Anesthesia Records and the Omission and Smoothing of Data 8.2.1.2 Rules, Fines, and Violations 8.2.1.3 Distinguishing between Violations and Errors: The “Decision Test” 8.3 Blurred Boundaries between Violation and Error: Fatigue as an Example 8.3.1 Fatigue and Alcohol 8.3.2 Tired Doctors 8.3.3 Working while Fatigued as an Example of a Necessary, Appropriate, or Correct Violation 8.3.4 A Deeper Dive into Fatigue and Safety 8.3.5 Fatigue as a Violation 8.4 Human Factors and Violation 8.4.1 Hard and Soft Engineering 8.4.1.1 Facilitating Compliance: Oxygen Monitoring and Informed Consent 8.4.1.2 Process Design and Medication Safety 8.5 Types of Violation 8.5.1 Routine Violations 8.5.2 Optimizing Violations and the “Hero” Culture in Healthcare 8.5.3 Exceptional, Appropriate, Necessary, and Correct Violations 8.5.4 Routine Violations, Normalized Deviance, and Changes in Practice over Time 8.5.4.1 Why Minor Violations Are Common: Speeding Anesthesiologists and Poor Hand Hygiene 8.5.4.2 Hand Hygiene and Anesthesia 8.5.4.3 Autonomy and Variation in Healthcare 8.5.4.4 Changes in Practice over Time 8.6 Medication Management, Systems, Practitioners, and Violation 8.7 Conclusions References 9. Interventions to Improve Medication Safety 9.1 Introduction 9.2 Culture 9.2.1 Leadership and a Comprehensive Medication (Patient) Safety Program 9.2.2 Incident Reporting Systems and Measurement More Generally 9.2.3 Root-Cause Analyses, Medication Event Huddles, Learning from Defects, and Medication Safety Walk-Arounds 9.2.4 Policies and Procedures 9.3 Technology 9.3.1 Electronic Management Systems (or Electronic Health Records) and Integration 9.3.2 Computerized Provider Order Entry 9.3.3 Electronic Medication Reconciliation 9.3.4 Automated Dispensing Cabinets 9.3.5 Barcode Technology 9.3.5.1 Inpatient Settings 9.3.5.2 Operating Room Settings 9.3.6 Smart Pumps 9.3.7 Route-Specific Small-Bore Connectors 9.4 Standardization, Storage, and Preparation 9.4.1 Equipment 9.4.2 Labeling 9.4.2.1 Tall Man Labeling 9.4.2.2 Color-Coding 9.4.2.3 Prefilled Syringes 9.4.2.4 The Storage, Preparation, and Concentrations of Medications 9.5 Pharmacy 9.5.1 Pharmacist Involvement in Care Delivery 9.5.2 Decentralized Pharmacy Services 9.5.3 Medication Ordering, Supply, Distribution, and Inventory Control 9.6 Teamwork, Communication, and Other Nontechnical Skills 9.6.1 Team Training 9.6.2 Structured Communication Protocols 9.6.2.1 Speak Back, Read Back, Phonetics 9.6.2.2 Briefings and Handoffs 9.6.3 Multitasking, Fatigue, and “Hero” Mentality 9.7 Conclusions References 10. Medication Safety in Special Contexts 10.1 Introduction 10.2 Medication Safety in Low- and Middle-Income Countries 10.2.1 Access to Healthcare in Low- and Middle-Income Countries 10.2.2 Access to Medications in Low- and Middle-Income Countries 10.2.3 The Influence of Recreational Use of Medications 10.3 Falsified and Substandard Medicines 10.3.1 Nature and Scope of the Problem 10.3.2 Interventions to Protect Against Falsified and Substandard Medicines 10.3.3 Preventing Substandard Medicines from Entering the Supply Chain 10.3.4 Detection of Falsified and Substandard Medicines 10.4 Interventions for Improving Medication Safety in Low- and Middle-Income Countries 10.4.1 Standardization 10.4.2 Pharmacy and the Use of Prefilled and Premixed Syringes 10.4.3 Technology and Equipment 10.4.4 Injection Practices 10.5 Medication Shortages 10.6 Wrong-Route Medication Errors 10.7 Psychiatry and Behavioral Health Units 10.8 Conclusions References 11. Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part I: General Principles 11.1 Introduction 11.2 The Objectives of a Legal or Regulatory Response to an Unintended Adverse Medication Event 11.2.1 Amelioration 11.2.2 Information and Open Disclosure 11.2.3 Compensation 11.2.4 Retribution and Punishment 11.3 Accountability and the Prevention of Future Harm 11.3.1 Some Thoughts on Possible Sanctions for Persistent Violation of Important Safety Practices in General 11.4 Ethics, Professionalism, and “the Team for Medication Safety” 11.4.1 Professionalism 11.5 Conclusions References 12. Legal and Regulatory Responses to Avoidable Adverse Medication Events, Part II: Practical Examples 12.1 Introduction 12.2 Internal Institutional Regulation of Medication Safety 12.2.1 Examples of Bottom-Up Efforts to Improve Medication Practices 12.2.2 Clinical Governance 12.2.2.1 Quality Accounts 12.2.2.2 Hard Measurement and Soft Intelligence for Managing Quality Accounts 12.2.2.3 Information from Patients 12.3 National and International External Regulation of Medication Safety 12.3.1 Accreditation 12.3.1.1 National Nongovernmental Agencies 12.3.1.2 National Governmental Agencies 12.3.1.3 Specialist Colleges and Other Training and Professional Organizations 12.3.1.4 Global Organizations 12.4 Civil Litigation and No-Fault Systems of Compensation 12.5 Criminal Law 12.5.1 The Case of Jack Adcock 12.5.2 The Role of Criminal Law in Responding to Failures in the Management of Perioperative Medications 12.6 Conclusions References 13. Barriers to Improving Medication Safety: Why Is Patient Safety So Hard? 13.1 Introduction 13.2 Safety Paradoxes 13.2.1 Measuring Safety via the Absence of Safety 13.2.2 Dangerous Defenses 13.2.3 Rigid Consistency versus Flexible Variability 13.2.4 Setting a Goal of Zero Events 13.2.5 Concentrating on Individual Human Error versus Team Error 13.3 Culture 13.3.1 Leadership Voids, Lack of Training 13.3.2 Power, Hierarchy, and Disruptive Behavior versus a Culture of Respect 13.3.3 Barriers to Incident Reporting: Fear of Retribution, Blame, or Shame 13.4 Financial Barriers 13.4.1 The Costs of Safety 13.4.1.1 Electronic Health and Pharmacy Systems 13.4.1.2 Prefilled Syringes 13.4.1.3 Frontline Staffing 13.4.1.4 Comprehensive Quality and Safety Programs 13.4.1.5 Productivity versus Safety 13.4.1.6 Balancing One Cost against Another 13.4.2 A Broader View of the Financial Benefits of Medication Safety 13.5 Human Nature 13.5.1 Violations 13.5.2 “I Won.’.t and You Can.’.t Make Me”: The Question of Clinical Autonomy 13.5.3 Lies, Damn Lies, and Statistics 13.6 Conclusions References 14. Conclusions 14.1 The Big Picture 14.1.1 The Global Level 14.1.2 The National Level 14.1.3 The Institutional and Departmental Level 14.1.4 Patients and the Public 14.2 Last Words References Index