Medication safety--reliability of preference cards.

A CLINICAL ANALYSIS of surgeons' preference cards was initiated in one hospital as part of a comprehensive analysis to reduce medication-error risks by standardizing and simplifying the intraoperative medication-use process specific to the sterile field. THE PREFERENCE CARD ANALYSIS involved two subanalyses: a review of the information as it appeared on the cards and a failure mode and effects analysis of the process involved in using and maintaining the cards. THE ANALYSIS FOUND that the preference card system in use at this hospital is outdated. Variations and inconsistencies within the preference card system indicate that the use of preference cards as guides for medication selection for surgical procedures presents an opportunity for medication errors to occur.

[1]  R. James,et al.  1000 anaesthetic incidents: experience to date , 2003, Anaesthesia.

[2]  E. Pierce,et al.  The 34th Rovenstine Lecture: 40 Years behind the Mask Safety Revisited , 1996, Anesthesiology.

[3]  D W Bates,et al.  Frequency, consequences and prevention of adverse drug events. , 1999, Journal of quality in clinical practice.

[4]  S. Frank,et al.  Improving pharmacy supply-chain management in the operating room. , 2000, Healthcare financial management : journal of the Healthcare Financial Management Association.

[5]  S. Beyea.  Safe Medication Practices in Perioperative Settings , 2006 .

[6]  S. Beyea.  Wake-up call--standardization is crucial to eliminating medication errors. , 2002, AORN journal.

[7]  P. Danneman,et al.  Monitoring of Anesthesia , 1993 .

[8]  J. Garrelts,et al.  Automated medication distribution systems and compliance with Joint Commission standards. , 2001, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[9]  D M Gaba,et al.  Anaesthesiology as a model for patient safety in health care , 2000, BMJ : British Medical Journal.

[10]  K. McDonald,et al.  Making health care safer: a critical analysis of patient safety practices. , 2001, Evidence report/technology assessment.

[11]  D. Blackstock,et al.  Medication Safety Alerts , 2004 .

[12]  C. Patterson,et al.  Joint Commission on Accreditation of Healthcare Organizations. , 1995 .

[13]  N. Girard,et al.  Standards, recommended practices, and guidelines. , 2006, AORN journal.

[14]  R. Hicks,et al.  Medication errors in the OR--a secondary analysis of Medmarx. , 2003, AORN journal.