Question

CRITICAL THINKING EXERCISE.

The operating room environment is complex in many ways. One of the complexities involves the way drugs are ordered, dispensed, handed over to scrubbed personnel, and nanded over to the surgeon for administration. The following statements about the drug process describe tasks and events that routinely occur in the operating room. How does each situation affect or cause specific drug errors? Provide one or more errors that can be attributed to the situation described. Be specific.

1. Surgical personnel use complex medications requiring mixing and dilution of drugs using a variety of devices.

2. Surgical personnel routinely transfer medications from one container and deliver de. vices to others for administration to the patient.

3. Standard guidelines require all drugs to be relabeled on the surgical field. This involves handwriting at least some of the required information on a small label. Scrubbed per- sonnel often use a skin marker that can smear and be washed over with blood or other fluids.

4. Surgical cases are often scheduled back to back with pressure to open up a case and set up quickly in order to maintain the surgical schedule.

5. The intraoperative environment is often noisy with the sounds of equipment, music, and talking.

6. Some drugs used during surgery are time sensitive. That is, they must be administered within a specified time limit after they are dispensed to the surgical field.

Answer 1

Operation room environment is complex. It is sterile and maintains possitive pressure to prevent outside air entry. In this described shedules there are chances for medication errors.

1) When surgical personnel use complex medications for mixing and dilution by using variety of devices. There are chances of errors. We use lot of infusion pumps in operation theatres, So when they prepare medicines and loaded in these devices errors can occur in the dose infusion rate etc.

2) When medicines transfered from one container and deliver devices to others, there are chances for errors to happen. If medicnes are not properly transfered or labelled, or transferd devices to other memebers also make mistakes.

3) When medicines are relabelled there are chances of manual errors. Skin markers are used by scrubbed persons in some instances. There are chances of washed over with blood or other fluids and which will lead to a medication error.

4) When surgeries are done back to back. It will create a busy shedule, so it will create a pressure on staff and there by risks for medication errors.

5) When OT atmospheres are noisy there are chances of destraction, some orders will not be audible. Which may lead to some errors.

6) Some drugs used in theatre are time sensitive, so if we did not follow the exact time it will end up in medication error and harm to the patient.

Two errors that occurs in this situations are

a) Scrubbed personnel use skin markers for surgical site marking not for drugs relabelling in surgical fields, So this is a wrong practice.

b) It is described that intraoperative environment is often noisy with the sounds of equipment, music, and talking. This is a wrong practice. OT atmosphere will be calm and quite and maintains strict discipline.