CONTINUING EDUCATION CE435
OnCourse Learning guarantees this educational activity is free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See page 40 to learn how to earn CE credit for this module. The goal of this continuing education program is to provide perioperative nurses, surgical technologists, and pharmacists with information about the challenges of and effective strategies for medication and solution labeling in the perioperative setting. After studying the information presented here, you will be able to: •D iscuss the intent of The Joint Commission’s National Patient Safety Goal NPSG.03.04.01 involving labeling medications and solutions on and off the sterile field • Identify the challenges for safe medication administration unique to the perioperative environment • Describe strategies for effective medication and solution labeling on and off the sterile field Everyone is familiar with the adage, “What you see is what you get.” But can healthcare professionals rely on it when it comes to safe medication administration in the perioperative setting — or should “Looks are deceiving” be their motto? This module explores patient safety goals and strategies for effective medication and solution labeling on and off the sterile field in the perioperative environment. Perioperative healthcare professionals and pharmacists must be knowledgeable about these concepts so they can promote patient safety and desirable outcomes.
WWW.ORTODAY.COM
SAFE LABELING HELPS PREVENT OR MEDICATION ERRORS SAFE PATIENT CARE
Safe and effective patient care is the core of perioperative practice. AORN (The Association of periOperative Registered Nurses), the professional organization of perioperative RNs, published the Perioperative Patient Focused Model, which recognizes that “there is nothing more important to the practicing perioperative nurse than his or her patient.”1 Publications such as AORN’s Guidelines for Perioperative Practice, articles in peer-reviewed journals, research, safe practice guidelines, and tool kits are valuable resources for safe patient care; however, failures in patient care processes and systems still occur and can result in errors in patient care.1 These occurrences and “near misses” can harm patients. When the error is detected before the care or treatment is administered (a “good catch”), patient harm is avoided. Sometimes, the care is administered but does not appear to cause patient harm. Unfortunately, sometimes the care, treatment, or medication is administered erroneously, resulting in temporary or even long-term harm to the patient. These negative outcomes, including medication errors, receive national attention when they become one of The Joint Commission’s (TJC) sentinel events. The Patient Safety Advisory Group (formerly the Sentinel Event Advisory Group), appointed by TJC in 2002, reviews and investigates reported sentinel events by
performing root cause analyses. Medication errors are reportable sentinel events. Fortunately, national attention to the administration and management of medications was not one of the top 10 sentinel events reported for 2014. A significant reduction in medication errors is noted. Sentinel event data compiled from 1995 to 2016 can be viewed at https:// www.jointcommission.org/assets/1/18/ Summary_4Q_2016.pdf. The Institute of Medicine’s 1999 report on medical errors, To Err Is Human: Building a Safer Health System, has made patient safety initiatives a priority for healthcare organizations and government agencies. In 2002, AORN launched the Patient Safety First campaign to reduce errors in surgical settings and create resources to help perioperative clinicians provide safe patient care. Specific practices include correct patient and surgical site verification and surgical counts, as well as medication safety, which can be found in the AORN Guidelines for Perioperative Practice. TJC first established its National Patient Safety Goals (NPSGs) in 2003, and the NPSGs continue to influence patient care. Goal 3 (improve the safety of using medications) addresses safe medication and solution administration. Perioperative care areas must meet the three specific requirements of Goal 3: • Label any medication that is not in its original container and place it into a syringe, cup, or basin July/August 2017 | OR TODAY
35