MA. CAMILLE SHAENE C.

CABIDOY GROUP D

Best practices for safe

medication administration
Recently, an inadvertent injection of chlorhexidine during a
radiological procedure led to the tragic death of a 69-year-old
grandmother named Mary McClinton. (1) This death, the result of
system errors, may have been preventable. Unfortunately, it follows a
number of other patient deaths that occurred as the direct result of
solutions being placed in unlabeled basins during surgical and other
invasive procedures. (2) Three years ago, Ben Kolb's parents'
appeared on a nationally televised show and told the story about their
seven-year-old son inadvertently being given epinephrine 1:1,000 as a
local anesthetic instead of the intended lidocaine with epinephrine--a
fatal error. (3) After the story aired, many individuals throughout the
country who are involved in health care took action to prevent similar
errors. AORN developed and disseminated its first guidance statement
regarding safe medication practices in perioperative practice settings
and launched the Patient Safety First initiative. Many individuals wrote
articles and columns related to medication safety in perioperative
settings, and a variety of speakers gave presentations on the topic.
Despite these efforts, patient deaths due to medication labeling errors
still occur. Placing liquids in unlabeled containers led to the patient
deaths described above, and similar situations continue to occur in
some health care organizations and clinical settings. Furthermore,
when health care providers began performing invasive procedures in
diagnostic and interventional settings rather than in the OR, personnel
caring for those patients may not have been aware of practices that
traditionally had ensured safety in perioperative settings. This lack of
knowledge, coupled with the fast pace of many interventional and
diagnostic departments, contributes to the potential for errors to
occur. What seems like a harmless activity (eg, not labeling liquids in
sterile basins) can easily lead to disaster.

The occurrence of medication errors emphasizes the important

role perioperative nurses play in spreading the word about best
practices during invasive procedures. These nurses should serve as
standard bearers for safe practices for minimally invasive or diagnostic
procedures performed outside the OR. Perioperative nurses have
significant expertise in the areas of surgical asepsis, safe medication
handling, and traffic control, and they serve instrumental roles in these
areas. They must share their expertise and clinical wisdom by coaching
and mentoring other individuals in surgical, invasive, and diagnostic
settings.