Postoperative Medication Errors in Otolaryngology

• Published in: Otolaryngology-head and neck surgery 2011-08, Vol.145 (2_suppl), p.P56-P56
• Main Authors: Gonzalez, Danny S., Antonelli, Patrick J., Winterstein, Almut
• Format: Article
• Language: English
• ISSN: 0194-5998; 1097-6817
• DOI: 10.1177/0194599811416318a50

Objective: The epidemiology of medication errors (MEs) in ambulatory and inpatient care is well understood, but little is known about ambulatory surgery. This study aims to quantify the incidence and nature of MEs after ambulatory otolaryngologic surgery. Method: Ambulatory surgery patients were assessed for 1) pre-surgical home medications, 2) clinical history, 3) written prescriptions, 4) discharge instructions, and 5) medication use reported by patients within 48 hours of discharge. Potential MEs were reviewed by an expert panel to determine validity, contributing factors, and potential preventative measures. Results: From 100 surgeries, 12 postoperative MEs were identified. All were without clinical sequelae, in part due to investigator involvement. Contributing factors included providers (2), patients (5), and the healthcare system (5). Causes for MEs included failure to verify patient information (eg, allergies), failure to accurately reconcile medications, and misunderstanding of instructions by the patients. Discharge instructions and medication reconciliation protocols appeared insufficient for optimal postoperative care and resulted in many after-hours calls for clarification. Conclusion: MEs are common following ambulatory otolaryngologic surgery even though regimens are simple and limited to few medications. Key targets for quality improvement include fragmentation in information flow and physician-patient communication.