6.errores en la suspension de medicamentos en el periodo perioperatorio

8/2/2019 6.Errores en La Suspension de Medicamentos en El Periodo Perioperatorio

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Medication discontinuity errors in the perioperative

period

J. A. R. VAN WAES1, J. C. DE GRAAFF

1, A. C. G. EGBERTS2 and W. A. VAN KLEI

Departments of 1Perioperative care and Emergency Medicine and 2Clinical Pharmacy, University Medical Centre Utrecht, the Netherlands

Background: Inappropriate withdrawal or continuation of medication in the perioperative period is associated withan increased risk for adverse events. To reduce this risk, itis important that patients take their regular medication asprescribed. We evaluated this treatment objective bystudying the frequency and reasons for errors related tomedication discontinuity in the perioperative period.Methods: Patients scheduled for non-cardiac surgery wereincluded in this cross-sectional study. Perioperative med-ication intake was assessed at the holding area of theoperation theatre complex and on the ward during thefirst 24 h after surgery. Medication intake data were ob-tained from medical records and by questioning patientsand compared with pre-operative instructions.Results: The study included 701 patients, of whom 485(69%) used regular medication. Medication was incorrectlytaken or discontinued before surgery in 27% of the pa-

tients. In 57% of these patients, the reason for incorrectintake was an unclear or a falsely understood instruction before surgery. Post-operative medication errors occurredin 26% of the patients.Conclusion: Medication errors occur frequently in theperioperative period, even in the era of an electronicmedication file. Errors in prescription, administrationand intake of medication are not easily solved because nosingle health care professional is responsible for adequateintake of medication in surgical patients. The anaesthesiol-ogist should take on a more prominent role in regulatingperioperative medication intake in surgical patients.

Accepted for publication 28 August 2010

r 2010 The Authors Journal compilationr 2010 The Acta Anaesthesiologica Scandinavica Foundation

PHYSICIANS caring for patients undergoing sur-gery are responsible for the perioperative man-

agement of a patient’s regular medication, andincorrect withdrawal or continuation of certainmedication in the perioperative period increasesthe risk for adverse events. For example, disconti-nuation of cardiac medication may increase the riskof perioperative myocardial ischaemia and incor-rect administration of antidiabetics could result inperioperative hypo- or hyperglycaemia.1,2

To reduce such risks, it is important that patients

take their regular medication in the perioperativeperiod as required, according to the underlyingdisease and the scheduled procedure. However,in 30–60% of the surgical patients, medication isincorrectly administered during the perioperative

period.3–7 Several factors may contribute to thediscontinuity of regular medications. On the dayof surgery, instructions about fasting, togetherwith instructions to continue regular medication before surgery, can be confusing both for patientsand for nurses, resulting in the discontinuation of medication intake. After surgery, post-operativenausea, vomiting or the presence of a nasogastrictube may complicate medication intake. Further-more, transfer from the post-operative anaesthesiacare unit to the ward at the time of regular admin-

istration of medication, together with inadequatecommunication, could interfere with the normalintake of drugs.2,5,6

In order to improve the management of perio-perative medication, it is essential to know thefrequency and the reasons for the undesired dis-continuity of medication in the perioperative per-iod. The present study examined the extent andreasons for unanticipated and undesired disconti-nuity of regular medications in the perioperative

This study has been presented as a poster presentation at the 2009NVA Annual Meeting (Dutch Association of Anesthesiology, 22 May2009, Maastricht, The Netherlands) and the 2009 ASA Annual Meeting (18 October 2009, New Orleans, Louisiana, USA).

r 2010 The Authors

Journal compilation r 2010 The Acta Anaesthesiologica Scandinavica Foundation

ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2010.02318.x

period among non-cardiac surgical patients hospi-talised for at least one night after surgery.

Methods

PatientsThis cross-sectional study included elective non-

cardiac surgery patients who underwent surgery atthe University Medical Centre Utrecht (the Nether-lands) in April and May 2008. Patients were hospi-talised after surgery for at least one night. Patientswho had not been seen for pre-operative assessmentat the outpatient clinic and patients with whomcommunication was complicated because of lan-guage, hearing problems or mental retardationwere excluded from the study. The study protocolwas approved by the local hospital ethics committee,which waived the need for informed consent, aspatients were not subjected to investigational ac-

tions. Patient confidentiality was guaranteed accord-ing to the Dutch law on personal data protection.

Routine perioperative careAfter the indication for surgery has been set by thesurgeon, the patient visits the outpatient pre-op-erative assessment clinic approximately 3 weeks before surgery. At this clinic, the health status of thepatient is evaluated by an anaesthesiologist or aspecialised anaesthetic nurse, who provides verbalinstructions about fasting and perioperative med-

ication.8

Approximately 1 week before admission,the patient receives a standard letter by mail withgeneral instructions about fasting and medicationintake together with the admission date. Mostpatients are admitted on the day of surgery, whichmeans that they are self-responsible to follow theprovided medication and fasting instructions onthe day of surgery.

Upon admission, the patient’s medication isprescribed electronically by the clinical ward phy-sician according to the pre-operative assessmentform and updated by medical history. Additional

medication, such as post-operative pain medica-tion, low-molecular-weight heparins and antimi-crobial drugs, is prescribed if indicated to everypatient who is admitted to a clinical ward aftersurgery, including for those patients who do nothave any own regular medication. After surgery,administration of medication is resumed at therecovery area of the operation theatre complex orat the clinical ward. All prescribed medication isadministered to the patient in regular scheduled

rounds by nurses on the clinical ward (with amaximum of four times a day) and documentedfor each patient in a medication file.

Another regime applies to patients who areadmitted after day case surgery with dischargethe morning after surgery (i.e. often within 24 hafter surgery). These patients are instructed to take

their own medication with them to the hospital andare self-responsible for the intake of their ownmedication (as if they were at home). Medicationintake in these patients is not documented in amedication file.

Study proceduresAbout 1 h before surgery, data on the instructionsof oral medication intake and actual medicationintake were recorded at the holding area of theoperation theatre complex. Patients were specifi-

cally asked which medication they were ordered(not) to take that morning according to the pro-vided instructions and which medication they hadactually taken. Furthermore, it was asked who hadgiven these instructions and whether or not theseinstructions were clear or conflicting. Data onmedication that should have been taken or discon-tinued by the patient were collected from the pre-operative assessment form. Paracetamol intake wasexcluded from pre-operative data collection, be-cause this drug was administered by protocol to allpatients 1 h before surgery.

Post-operative data were recorded from the med-ication file on the clinical wards up to 24 h aftersurgery. It was established whether the medicationprescribed in the hospital was consistent with theregular medication taken at home as documented inthe pre-operative assessment file, and whether thismedication was administered during the first 24 hafter surgery on the clinical ward. Subsequently,patients were interviewed regarding whether themedication prescribed and administered was actu-ally taken during these first 24 h. If not, the reasonsfor discontinuity were obtained. Patients who were

admitted to the ICU after surgery were excludedfrom post-operative data collection because of diffi-culties in obtaining data. Parenteral drugs, laxatives,creams and unguent, eye drops, ear drops, oralcontraceptives and medication only taken on de-mand were not taken into account.

Both pre-operative and post-operative data werecollected by one of the authors (J. A. R. v. W.) andfour research nurses using an electronic case reportform.

J. A. R. van Waes et al.

who (in)correctly took or discontinued their regu-lar medication, divided into six groups of medica-tion. Analgesics and anticoagulation drugs werenever taken incorrectly, but six (14%) of the 43patients on oral antidiabetics took this medicationincorrectly (Fig. 1). In 13 cases (3%), it was notpossible to find out whether medication should

have been taken or not or which medication wasactually taken. For 122 (30%) of all 408 patients whoused regular medication, instructions about medi-cation intake before surgery were not clear. Of the111 patients who incorrectly took or discontinuedtheir medication, in 65 cases (59%), the reason forincorrect intake was an unclear or a falsely under-stood instruction (Table 2). In none of the 111patients who incorrectly took or stopped theirmedications the surgery was delayed because of medication discontinuation. Furthermore, none of the patients who incorrectly took their oral anti-

diabetics developed hypoglycaemia.

Post-operative medication intakeOf the 375 patients for whom post-operative datawere available, 276 (74%) used regular medication(Table 3). In 270 (72%) of the 375 patients, one ormore of four medication gifts were not recorded because data collection took place within 24 h aftersurgery (i.e. in general, data on the last gift werenot recorded). In 98 (26%) patients, any medicationerror occurred during the first 24 h after surgery,

and in 82 (22%), an error occurred in the adminis-tration of medication (gifts and/or intake).

In 174 (46%) of the 276 patients using regularmedication, this medication was prescribed on theclinical ward and 102 (27%) patients managed theirregular medication themselves. In 23 (13%) of the

Fig. 1 Medication intake before surgery. Each column showsthe percentage of patients who (in)correctly took or discontinuedtheir regular medications, divided into six groups. The numberof patients who used regular medication is given for each groupof medication above each column. The number of patients of all six

groups together exceeds the total number of patients on regularmedications (N5408), because most patients used two or moremedications and were therefore counted in more than one group.

If a patient used more than one drug from the same group, of whichone was correctly taken and one was incorrectly discontinued,(s)he was counted in ‘incorrectly withdrawn’ within that groupof medications.

Table 2

Reasons for the incorrect intake of medication before surgery(n 5111).

Instruction unclear or falsely understood 65 (59)Not administered on clinical ward 17 (15)

Forgotten 10 (9)Contradictory instructions 6 (5)Refusal by patient 4 (4)Lack of time 4 (4)Other 3 (3) 1 reason 2 (2)

Figures are numbers of patients (%).

Table 3

Medication intake after surgery.

All patients

Incorrect prescription of

regular medication*

Incorrect administration or intake

of prescribed medicationw

82)Regular medication use 276 (74) 23 (8z) 73 (26z)

Prescribed on clinical ward 174 (46) 23 (13z) 40 (23z)In self-management 102 (27) NA 33 (32z)

No regular medication use 99 (26) NA 9 (11z)

Given are the numbers of patients for whom regular medication was incorrectly prescribed on the clinical ward (middle column) and thenumbers of patients in whom the prescribed medication was incorrectly administered or not taken after surgery (right column).Figures are numbers of patients (%).*Incorrect prescription means that one or more of the regular medications were not prescribed or that there was a discrepancy in drugor dose.wIncorrect administration or intake means that the prescribed medication was not administered or not taken by the patient.zFigures are row percentages.

174 patients who had their regular medicationprescribed on the ward, an error occurred in theprescription. Thirty-three patients (32%) who man-aged their medication themselves had errors inintake, compared with 40 (23%) of the patientswho had their medication prescribed by the wardphysician (RR 1.6, 95% CI: 0.9–2.8) (Table 3).

The medication involved in errors included allkinds of medication (Table 4). The reasons for the

incorrect administration or intake of medicationafter surgery were, among others, that it wasunclear whether the regular medication shouldhave been continued or not, or nausea and vomit-ing (Table 5).

Discussion

This study showed that errors in the prescription,administration or intake of medication in the peri-

operative period occur in a substantial number of patients. We found that surgery was not delayed inany of the patients who incorrectly took or stoppedtheir medications before surgery. In this study,none of the patients incorrectly took anticoagulantswhile they should not have. In such cases, however,surgery may have been postponed by the surgeon before the patient was sent to the holding area of the operation theatre complex. Therefore, thesepatients were probably not included in our study.

The incidence of medication errors in our study(27%) is lower than reported earlier (30–60%),3–7

possibly because instructions about the continua-tion of medication around surgery have improvedover the last decade. Previously, fasting was re-ported as the main cause of error in medicationintake.4–6 In the present study, medication discon-tinuity was mainly (59%) caused by apparentlyconfusing instructions for fasting and continuationof medication intake. During the first 24 h aftersurgery, errors in medication prescription, admin-istration or intake occurred in 26% of the patients.

Kluger et al.5

found similar figures; one third of thesurgical patients did not receive their medicationon the day after surgery. Earlier studies on pre-scription errors reported that 10–61% of the pa-tients had at least one omission error in theirprescribed medications at the time of hospitaladmission.9 We showed that these errors (mostlydiscontinuation of medication) still occur fre-quently, even though an electronic medication fileis being used and that these errors also occur when

Table 4

Medication that was incorrectly prescribed, administered or taken after surgery.

Incorrect prescription of regularmedication* (N 523)

Incorrect administration or intakeof prescribed medicationw (N 582)

Analgesics, other than opioı̈ds 2 (9) 38 (46)b-Blocker 1 (4) 1 (1)Diuretic 3 (13) 2 (2)Calcium channel blocker 0 2 (2)

ACE-inhibitor or ATII-receptorantagonist 4 (17) 2 (2)Statins 1 (4) 3 (4)Pulmonary medication 2 (9) 1 (1)Gastric medication 2 (9) 2 (2)Antiepileptics or psychopharmaca 6 (26) 6 (7)Antidiabetics 0 0Anticoagulation 0 0Other/not specified 2 (9) 25 (30)

The left column shows the number of patients (%) in whom medication was incorrectly prescribed on the clinical ward, and whichmedications. The right column shows the number of patients (%) in whom medication was incorrectly administered or taken.Figures are numbers of patients (%).*Incorrect prescription means that one or more of the regular medications were not prescribed or there was a discrepancy in the drugor the dose.wIncorrect administration or intake means that the prescribed medication was not administered or not taken by the patient.

Table 5

Reasons for incorrect administration or intake of medicationafter surgery* (n 582).

Unclear whether medication should be taken or not 13 (16)Nausea or vomiting 6 (7)Not received by the patient 6 (7)Nasogastric tube/Not being able to swallow 3 (4)Refusal by the patient 3 (4)Medication in self-management, but not available 2 (2)Other or not specified 49 (60)

Figures are numbers of patients (%).*

Incorrect administration or intake means that the prescribedmedication was not administered or not taken by the patient.

Perioperative medication discontinuity

the patient is self-responsible for medication man-agement. Unfortunately, in some patients, datawere collected before the last (fourth) administra-tion of medication during the first 24 h after sur-gery had taken place. In most of these cases,however, an error occurred in the first or thesecond medication gift after surgery.

Our post-operative data show that both physi-cians and nurses on the ward were unaware as towhether or not certain medication had to be con-tinued. The post-operative oral intake of medicationis also complicated by limited routes of administra-tion in patients who cannot take medications orallyafter surgery, for example in maxillofacial surgery.2

This might be solved by clear instructions designedindividually for each patient about continuation andalternative ways of administration of medication.Furthermore, alternative medication routes for oralmedication should be mentioned and be available on

the ward even before admission of the patient.We found more post-operative intake errors inpatients who had their medication in self-manage-ment. A considerable number of these patientswere not able to continue their regular medicationas they should, because it was not clear for themwhether they should continue their medication ornot. Even if patients know that medication should be taken, it is reasonable that patients after such amajor event as surgery forget to take their medica-tion because of post-operative confusion by opiatesand sedatives. In our opinion, these figures illus-

trate that post-operative patients should not man-age their medication themselves.

In the present study, both medical charts andanswers from patients were used to obtain dataabout medication intake before and after surgery.Medication that was administered according to themedication file but, for whatever reason, was nottaken by the patient was also reported as an error.Therefore, we could not only determine how manypatients did not adequately take their regularmedication but also at which point in time theerror in the process of prescribing, administering

and finally taking medication occurred. In previousstudies, errors in this step of medication intakeafter surgery were not recorded. Still, obtainingdata by asking the patient just before surgery mightresult in uncertain answers, because of stress orsedation by premedication. Because most patientsare admitted to the hospital on the morning of surgery, we considered no other moment appro-priate to collect these data than just before surgery.Furthermore, premedication is prescribed infre-

quently in our hospital. Asking the patient mightalso result in bias due to socially desirable answers,which we attempted to overcome by using inter-viewers who were not involved in daily care. Whilecollecting data, in many cases (60%), it appeared to be impossible to find out the reason for inadequateadministration or intake. Surprisingly, in all these

cases, it could not be obtained from nurses nor fromthe medication file and patients themselves were notaware why certain medication was not administered.Obviously, this finding can be considered as a resultin itself: even in the era of electronic medication files,it remains difficult to document the reasons for (not)prescribing or administering regular medication to apatient. Although there might be valid reasons fordoing so, other professionals involved in patient care(e.g. physicians or hospital pharmacists) will beunaware of the reasons why medication actually is(not) prescribed.

The ‘instruction unclear or falsely understood’,‘forgotten’ and ‘lack of time’ might be seen aspatient-related causes of errors. In our opinion,however, all reported errors can be considered to be hospital-related system errors as in fact the pre-operative work-up system should ensure that pa-tients continue their medication correctly and alsocheck and correct potential patient-related errors.Medication errors in the perioperative period arecompounded by a fragmented approach to perio-perative drug therapy, together with a lack of responsibility of a specific group of healthcare

professionals.2

In our hospital, the ward physician,the anaesthesiologist and the surgeon all shareresponsibility for correct prescription of medica-tions in the perioperative period. Preferentially, asingle specialist should be responsible for theperioperative medication prescription. An interest-ing option to prevent errors is to involve a phar-macist in this process. Kwan et al.7 showed that thenumber of prescription errors related to regularmedication reduced from 40% to 20% when apharmacist took part in prescribing medication.

To prevent errors in prescription, regular medi-

cations and commonly prescribed medicationssuch as post-operative analgesics and low-molecu-lar-weight heparins could already be prescribedwhen the patient is seen at the pre-anaesthesiaevaluation clinic by the anaesthesiologist. At thisvisit, the anaesthesiologist should instruct the pa-tient about the perioperative intake of medication,and written information should be provided. Also, because a number of patients will not fully remem- ber these instructions by the time they have to

undergo surgery, individually targeted medicationinstructions should be sent with the patient byletter just before surgery. On admission, a nursecould check whether the medication is continued by the patient according to the given instructions.Medication that is incorrectly not taken could yet be administered before surgery, and information

about medication that is incorrectly taken should be discussed with the anaesthesiologist. A nursetogether with the patient could check whether themedication is prescribed according to the actualregular medication by using a checklist. The wardphysician and a pharmacist can solve any problemswith prescription.

The anaesthesiologist should take on a moreprominent role in regulating medication intake inthe perioperative period. The visit of each patient tothe pre-operative assessment clinic before surgeryprovides good opportunities to accomplish this.

References

1. Kennedy JM, van Rij AM, Spears GF, Pettigrew RA, Tucker IG.Polypharmacy in a general surgical unit and consequences of drug withdrawal. Br J Clin Pharmacol 2000; 49: 353–62.

2. Noble DW, Webster J. Interrupting drug therapy in theperioperative period. Drug Saf 2002; 25: 489–95.

3. Duthie DJR, Montgomery JN, Spence AA, Nimmo WS.Concurrent drug therapy in patients undergoing surgery.Anaesthesia 1987; 42: 305–6.

4. Wyld R, Nimmo WS. Do patients fasting before and afteroperation receive their prescribed drug treatment? Br Med J 1988; 296: 744.

5. Kluger MT, Gale S, Plummer JL, Owen H. Peri-operativedrug prescribing pattern and manufacturers’ guidelines: anaudit. Anaesthesia 1991; 46: 456–9.

6. Pearse R, Rajakulendran Y. Pre-operative fasting and admin-istration of regular medications in adult patients presentingfor elective surgery. Has the new evidence changed practice?Eur J Anaesthesiol 1999; 16: 565–8.

7. Kwan Y, Fernandes OA, Nagge JJ, Wong GG, Huh JH, HurnDA, Pond GR, Bajcar JM. Pharmacist medication assess-ments in a surgical preadmission clinic. Arch Intern Med2007; 167: 1034–40.

8. van Klei WA, Hennis PJ, Moen J, Kalkman CJ, Moons KG. Theaccuracy of trained nurses in preoperative health assessment:results of the OPEN study. Anaesthesia 2004; 59: 971–8.

9. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R,Etchells EE. Frequency, type and clinical importanceof medication history errors at admission to hospital: asystematic review. CMAJ 2005; 30: 510–5.

Address: Judith A.R. van WaesDepartment of Perioperative care and Emergency MedicineUniversity Medical Centre UtrechtLocal mail Q04.2.313PO Box 85500, 3508 GA UtrechtThe Netherlandse-mail: j.a.r.vanwaes@umcutrecht.nl

Perioperative medication discontinuity

6.errores en la suspension de medicamentos en el periodo perioperatorio

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