Lessons we can learn from safety incidents in PACUs and recovery areas: ISMP Canada

A patient is discharged from a post-anesthetic care unit (PACU) to a nursing unit. But once there, the staff notices the patient is lethargic, pale, hypotensive and looks unwell. They are transferred to the ICU and found to have internal bleeding. This incident was one of 49 that the Institute for Safe Medication Practices Canada (ISMPC) analyzed in a recent bulletin focused on post-anesthetic care units (PACUs) and other recovery areas. In this case, an investigation found that the PACU had missed some warning signs of instability, and that a tranexamic acid IV infusion had been inadvertently stopped while the patient was in the unit. Read: Hospital-acquired hyponatremia risks and solutions: ISMP CanadaMost cases aren’t this serious: only nine that the ISMPC looked at led to mild or moderate harm, with the rest being near misses. It found that incidents fell into three general buckets: the transfer of accountability (played into 37% of incidents); medication administration (part of 31.5%); and hybrid documentation systems (31.5%). Within the transfer of accountability, there were incomplete handovers, like missed information about allergies and miscommunications around medication orders and time-sensitive dosing. It also included the transfers of patients who were unstable from areas with close monitoring and specialized nursing to those that prepare patients for discharge.In one case, a nurse in a PACU gave a patient who had both a G-tube and J-tube medications through his G-tube. The nurse was unaware that the patient could only tolerate medications through the J-tube, even though the OR team had been told this. The patient aspirated the medications and developed aspiration pneumonia. Read: ISMP Canada analysis highlights errors that can happen with look-alike high-alert medicationsWithin the theme of medication administration, there were three subcategories. The first was high-alert medications: more than half of the reported incidents involved high-alert medications such as opioid analgesics and vasoactive medications. Missed allergy verification and pre-pouring medications also contributed to incidents. In one case shared, a nurse mistakenly gave a patient 5 mg of phenylephrine instead of the ordered ephedrine 5 mg IV. An anesthesiologist had already administered a dose of phenylephrine to the patient, who had low blood pressure. Finally, hybrid documentation systems, which use both paper and electronic records, can cause confusion. Perioperative care areas that use a paper-based system have a high risk of medication omissions. For example, in one case, a PACU was given a patient pre-admission medication list, but it wasn’t scanned and sent to the hospital pharmacy (which was against the hospital’s protocols). As a result, the patient missed multiple doses of their regular medications over the next day. The analysis contains 15 recommendations to reduce the risk of errors (the full list can be found here). They include reassessing workflows to minimize pre-pouring and other workarounds; standardizing handover procedures; adding independent double checks to administering IV push medications and programming smart infusion pumps; and checking for vital signs, pain assessment and dressing just before transferring patients out of the PACU.Read: Resist temptation to pre-pour medications: ISMP Canada

Lessons we can learn from safety incidents in PACUs and recovery areas: ISMP Canada

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