Best Practices for Safe Medication Administration

Best Practices for Safe Medication Administration

S45--56-Supp4_SafeMeds 6/26/06 11:34 AM Page S45 Case Study 1 Retinal surgery is often performed with a surgical microscope in a darkly lit oper...

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Retinal surgery is often performed with a surgical microscope in a darkly lit operating room. The ceiling lights and overhead surgical lighting are turned off during most of the procedure. The microscope light illuminates only a very narrow field in the eye while the surgeon works on the retina. On the day of this near miss, the lights were off in the room. The surgeon instructed the surgical technician to obtain a specific amount of medication for injection into the eye. The surgical technician had to aspirate the medication from a vial held by the circulating nurse. The surgical technician drew up the small quantity of medication in a tuberculin syringe. After drawing up the medication, she gave the syringe to the surgeon, who inserted the needle into the eye. Just before the surgeon injected the contents of the syringe into the eye, he glanced at the syringe and said there was no medication in the barrel. Instead, air had filled the chamber of the barrel. He removed the syringe without injecting the air. When the surgeon made the remark, the surgical technician and the circulating nurse both realized what had happened. They both commented that “it is hard to see what you are doing in this dark room.” It was obvious to them that the surgical technician penetrated the rubber stopper of the medication vial and advanced the needle beyond the level of the medication. Neither the technician nor the circulating nurse could see the position of the needle in the vial. When the surgical technician withdrew the plunger to aspirate the medication, she was really aspirating air. The room was so dark that the surgical scrub technician was not aware of the problem when she placed the syringe on the back table or when she picked up the syringe and passed it to the surgeon. The technician did not notice the empty barrel until the surgeon held the syringe under an area illuminated by the microscope light. The darkness of the room was definitely a contributing factor. In retrospect, it was unlikely that the scrub technician was able to read the vial or see the vial contents when she was inserting the syringe needle. Prevention of incidents such as this should include • allowing for discrete areas of the OR and sterile field to be illuminated when necessary for identification of medications or other items in a darkened room, and • applying this practice to other specialties.

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From SafetyNet

Best Practices for Safe Medication Administration

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During the 3:30 pm shift change, an emergency procedure was set up by the day-shift scrub nurse who, after setting up the case, left without giving report to her staff member replacement. The replacement nurse scrubbed for the procedure. When she reviewed the procedure setup, she was unable to determine what fluids were in the medication cups because they were unlabeled. The RN who poured the medications could not identify which container held which medication, either. The scrub nurse threw the medications into the trash, and the RN circulator dispensed new medications.

A new RN employed at our facility has a mild language barrier; she speaks English well but has some difficulty understanding what is being said to her. She is pleasant and always asks for clarification when not sure of what is being asked of her. Today she passed incorrect medication to the sterile field. She was asked for “Pitressin” (vasopressin) and provided “Pitocin” (oxytocin) instead. She showed the vials to the surgeon, who distractedly glanced at them and agreed that the medication was correct. After the procedure was finished, she had second thoughts about what was ordered and approached the charge nurse. She showed the charge nurse a sheaf of papers hanging in the medication room, which showed Pitressin and Pitocin on the same line. She assumed that this meant the different names were the same medication. When the charge nurse investigated the situation further, she discovered that the face sheet of this sheaf of papers was titled “Use Caution—Dangerous Mistakes.” The paper was intended to educate staff members about the potential for confusion with similar sounding drugs. The charge nurse removed the cautionary list from the medication room. The charge nurse explained the error to the new RN and instructed her to file a medication occurrence report and to report the error to the physician.

Our facility employs allied health care personnel to assist registered nurses in providing care to clients. On one occasion an allied health support person was given medication packets for a discharge-status client. The wrong medication packet was given to the client. The nurse discovered the error, and no harm occurred to the patient.

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Improving Outcomes he Institute of Medicine (IOM) report To Err Is Human: Building a Better Health System identified medication errors as accounting for “one out of 131 outpatient deaths and one out of 854 inpatient deaths.”1 Medication errors can occur throughout all phases of medication administration, triggering substantial threats to patient well-being. No single health care provider group or step in the medication administration process is exempt from error. The unique nature of the perioperative setting creates additional challenges giving rise to increased risk for medication errors. Related factors affecting medication administration in this environment include the aseptic dispensing of medications onto the sterile field, an intermediary to receive and transfer dispensed medications to the scrubbed licensed practitioner (eg, surgeon), and the time-sensitive conditions in combination with sensory distractions intrinsic to the environment. Blending human performance with complex technology adds another dimension to perioperative medication administration. These factors amplify the potential for miscommunication leading to medication administration mistakes. This unique process necessitates the attention of the entire perioperative team.

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Challenges to Safe Medication Practices Specific concerns associated with medication errors in the perioperative setting include • inconsistent practices to communicate current and previous medication regimens (ie, medication reconciliation); • muffled verbal orders delivered through surgical masks may contribute to confusion in the medication order (eg, name, strength, dose); • incomplete, ambiguous, incorrect and/or illegibly written or spoken orders; • inaccurate, illegible, or outdated surgical preference cards;

• aseptic delivery of medications onto the sterile field that often requires removal of the contents from the original manufacturer’s packaging; • limited knowledge of medications by scrubbed allied heath care providers receiving medications onto the sterile field; • inconsistent labeling of medications on and off the sterile field; • transfer of dispensed medications to the administering individual by the scrubbed allied heath professional; • high-alert medications available in multiple dose forms and concentrations; • look-alike and sound-alike medications stored in close proximity; • increased patient care complexity requiring rapid perioperative interventions; • extended work-hours fatigue combined with a fast-paced environment; and • multiple health care providers throughout the continuum of perioperative patient care (ie, patient hand-off).2

Primary Recommendations There are multiple approaches to enhance medication administration in the perioperative environment. Crossdisciplinary literature identifies key strategies and considerations for global improvements in medication practices.1,3-5 The following are believed to be crucial to improving medication administration processes in the perioperative setting. Communication • The use of active communication is necessary to validate verbal and written perioperative medication orders and to confirm that each medication is dispensed aseptically onto the sterile field and before delivery to the licensed professional administering the medication. • Verbal read-back after the initial intraoperative medication order is given and during transfer of prescribed medications to the sterile field are key components of this process. aorn journal • S47

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• Perioperative clinicians should communicate the medication name and strength by labeling all medication containers on and off the sterile field. • Team members should use labels to identify the medication name, strength, and dose (ie, amount), and include the date and time if the medication will expire before the surgery or procedure is completed.2,5 • The scrub nurse and circulating RN should verbally and visually verify labels before the circulating RN dispenses medications onto the sterile field.2 • During change of shift or when a member of the perioperative team is relieved, “all medications, medication labels, and the amount of the medication administered should be verified concurrently by entering and exiting personnel.”2 • Collaboration between physicians, perioperative nurses, and pharmacists is needed to identify routine medications and doses used in surgery and to regularly update physician preference cards. • Collaborative discussions of intraoperative medication requirements and the patient’s preexisting and concurrent medication regimen during the immediate preoperative “timeout” or “briefing” period will protect the patient from unnecessary harm. • Formulate a comprehensive communication process that alerts the patient care team to the medications the patient has been taking or will be on throughout the health care encounter up to and including discharge. Incomplete communications during the patient hand-off period is linked to increased medical error in addition to adverse medication events. A medication reconciliation process is a critical element in patient hand-off communications.

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Workplace Controls • Perioperative work schedule requirements should be modified to minimize the risk of fatigueinduced errors. • Eliminate problematic workplace factors associated with staff member distraction and medication error such as poor lighting, cluttered work spaces, noise, and interruptions.4 • Standardize medication processes and dosage calculations by providing sterile unit-dose medications that can be aseptically delivered to sterile field in the original manufacturer’s package with a secondary label that can be used to identify the medication in the administration device (eg, syringe). • Store medication with consideration given to separation of look-alike and sound-alike drugs and solutions. • High-risk or problem-prone medications should not be stored alphabetically and manufacturers should continue to be encouraged to use distinctive labeling for medications and solutions. • Remove concentrated electrolytes (eg, potassium chloride, potassium phosphate, and sodium chloride above 0.9%) from the perioperative setting. • Dispensing of concentrated electrolytes for perioperative interventions should occur in collaboration with the clinical pharmacist. • Develop a standardized process for medication reconciliation. All perioperative clinicians should actively participate in a medication reconciliation process to ensure an accurate account of all medications the patient is currently taking or has received during treatment.

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Knowledge-Based Improvements • Provide readily available, patientspecific information to facilitate identification of medication allergy interactions, medication-medication or medication-herbal interactions, and contraindications.2 • Obtain patient weight in both pounds and kilograms to eliminate calculation discrepancies. The IOM cites poor mathematic and drug calculation skills by nurses and time constraints for calculations among the contributing factors for medication error.3(p240) • Facilities should consequently provide weight-conversion charts and standardized medication protocols for quick reference. Inconsistencies in a weight or dose calculation should result in the patient’s reevaluation and the weight recalculated.2 • Classification of high-risk and highalert medications should occur in each health care facility to safeguard against error.2,4,5 • Creation of dose conversion charts (electronic or written document) for high-risk or problem-prone medications should be readily available for clinicians to reduce reliance on memory lists and to aid in safe handling during use. • Continuing education and review of safe medication practices in the perioperative setting should occur annually. Department leadership should establish baseline competencies and education guidelines (eg, patient populations, age-specific criteria, calculation proficiency) regarding individual medications, high-alert medications, and medication error prevention strategies.2,4 Additional considerations for safe handling of medications in surgical and procedural settings include retaining the original medication or solution container and medication delivery device until the patient leaves the room. Should a need

arise to review the solutions used during the procedure; these items may assist in a root cause analysis of the situation. Accurate documentation contributes to the continuity of patient care delivery and validates perioperative nursing interventions performed to protect the patient. Documentation should reflect the Perioperative Nursing Data Set patient outcome O9, “The patient receives appropriate mediations, safely administered during the perioperative period.” Perioperative documentation should include the related nursing diagnoses (eg, risk for injury, X29) and those interventions leading to the desired outcomes (eg, “Verifies allergies,” I123; “Administers prescribed medications and solutions,” I8; and “Evaluates response to medications,” I51).6 Documentation of the patient care experience is one component of health care reporting. When untoward events occur in the medication management and administration process, perioperative nurses are obligated to report the incident according to facility guidelines. By providing this information in the anticipated time frame, the health care organization can systematically evaluate factors contributing to the event. Long-term aggregation of data also contributes to organizational understanding of why medication errors occur and is used to initiate practice enhancements. This information may be identified as reportable criteria to local or national regulatory agencies in an effort to establish error reduction strategies, health care system or process redesign opportunities, and as a means to evaluate the effectiveness of existing activities to reduce medication related error.7 Perioperative patients will benefit from professional advocacy for safe medication practices. Multidisciplinary collaboration combined with the implementation of technology to enhance human performance is key elements in establishing a safer environment for perioperative patient care.

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Analysis Case Study Analysis

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Questions that could be explored to help understand the contributing factors for this near miss include the following. • What additional measures could the RN circulator and surgical technician include in their practice to support safe medication practices? • Which communication recommendations for safe medication practices were not followed in this case study? • What other steps could be taken to help improve safe medication practices at this facility? The situation described in this case study is the classic “accident waiting to happen.” The need to perform retinal surgery in a completely darkened room must be weighed against the risk of error and patient harm. Developing work environments that promote safe medication handling practices have been cited as a means to reducing medication administration error.3 The “AORN guidance statement: Safe medication practices in perioperative settings across the life span” recommends the use of a lighted work surface during procedures that necessitate the room being darkened (eg, laparoscopic, ophthalmologic, endoscopic).2 The RN circulator is responsible for accurately dispensing medications onto the sterile field. This process includes a concurrent verification of the medica-

tion performed by the circulator and the receiving individual by audibly reading the name of the medication from the manufacturer’s label, the expiration date, and confirming that the pre-labeled containers and medication delivery device are accurately identified. If the environment is not conducive to the safe provision of the medication (eg, insufficient light to read the medication name), corrective actions should be taken before completion of the task. A hospital-approved lamp, flashlight, or surgical light on a low setting and positioned away from the operative area may be used to perform the verification process and will permit OR team members to see the medication vial, its contents, and the transfer of the solutions. In addition to low-light illumination of the work surface, highly predictable procedures (eg, cataract surgery) may allow medications to be prepared before the patient is brought into the operative suite. When the medication is transferred to the licensed professional responsible for administration, the transfer device label should be communicated and re-verified by the accepting individual. The surgeon should actively participate in the verification process to ensure that the correct medication, strength, and concentration will be administered.

Questions that could be explored to help understand the contributing factors for this near miss include the following. • What factors contributed to the absence of labeling in the near miss? • How could one determine whether this occurrence is an example of an isolated event or common practice at this facility?

• What steps could be taken to improve hand-off communication and help nurses maintain the sterile field in this case study? Unlabeled medication containers and delivery devices are factors associated in perioperative adverse medication events.8–11 One of the earliest stories reported to the Joint Commission on Accreditation of Healthcare

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Organizations (JCAHO) occurred in 1997 and resulted in the death of a sevenyear-old child scheduled for an elective tympanomastoidectomy. The root cause analysis of this event revealed a medication mix-up and unlabeled syringes.12 The Institute for Safe Medication Practices (ISMP) 2004 Medication Safety Self Assessment for Hospitals found only 41% of hospitals participating in the assessment had labeled all containers in surgical settings. AORN, supporting ISMP, the US Pharmacopeia (USP), and JCAHO’s National Patient Safety Goal 3, “Improve the safety of medications,” called for a National Time Out Day in June 2005 to focus on the necessity of accurately labeling all medications on and off the sterile field, regardless of the number of medications being used.13 AORN’s guidance to perioperative nurses first included the labeling of medications as a fundamental step for safe perioperative medication practices in 2002, with the creation of the “AORN guidance statement: Safe medication practices in perioperative practice settings,” and again in 2003 with the inclusion of “Recommended practice III: Potential hazards associated with medication use in the practice setting should be identified, and safe practices should be established”in the “Recommended practices for safe care through identification of potential hazards in the surgical environment.”14 The day-shift scrub nurse did not follow standards of practice when she abandoned the sterile field. AORN’s “Recommended practices for maintaining a sterile field” states, “A sterile field should be maintained and monitored constantly.”15 This apparently time-sensitive individual set up an emergency procedure and subsequently broke scrub before her relief was available, leaving the sterile field

unmonitored. It is unknown whether the circulating nurse was in attendance or was occupied with the needs of a critical patient outside the operating room. By directly observing the sterile field, the presence of the scrub person would help to identify any breach in sterility.15 The decision for this scrub person to leave the room at the end of her shift may potentially have increased the compromised patient’s risk for surgical site infection. The case study does not reveal whether the incoming scrub nurse was in the room at the time the day-shift scrub person left or the status of the patient’s arrival. Regardless, there was a break in the continuum of patient care because the vital exchange of information from one scrub person to another did not occur. There was no review of the equipment and supplies, and no discussion regarding the medications on the sterile field. The omission of medication labels on the solution containers is acutely apparent. The incoming scrub nurse appropriately questioned the solutions. She was wrong, however, to ask the circulating nurse to determine which medication was poured in which container. It is possible that the previous scrub person could have changed the position of the containers during the case setup. The best approach was taken when the relief scrub person disposed of the unknown medications into the trash. Unfortunately, the actions of the first scrub person caused additional effort on the part of the circulating nurse who was required to replace the original medications. If the patient had arrived into the surgical suite, this situation could have caused an additional escalation in stress for the perioperative team members and resulted in a chain reaction of potential medical errors.

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Questions that could be explored to help understand the contributing factors for this near miss include the following. • How did the new tool in the clinical environment contribute to this event? • What cultural and language barriers were present, and how did they contribute to this near miss? • What additional measures could be taken to minimize or avoid confusion for clinicians when introducing medication warnings? In 2001, 15% of all reports submitted to the USP Medication Errors Reporting Program between January 1, 1996 to December 31, 2000 were a result of look-alike and sound-alike medications.16 The extensive updated list published in March 2001, “Use caution—Avoid confusion,” was intended to alert health care professionals to the potential problems associated with more than 750 medication names. The Joint Commission subsequently published a Sentinel Event Alert based on the USP document that following May.17 Many facilities download the document from the USP web site for reference; the USP makes the 2001 document available to health care professionals in poster format or laminated reference card at no cost.17 Ordering information can be obtained by contacting USP’s Practitioner and Product Experience department at (800) 487-7776. When introducing a new tool to the clinical environment, department staff members should receive a thorough review of the tool including instruction on its use. It should never be assumed the end-user will read accompanying instructions, especially in rushed practice settings. As with the novice practitioner, detailed instruction and education afford assurance of the seasoned clinician’s comprehension of new information. With regard to this scenario, the new RN should have had an orientation to the posted document, including its significance. The intent placing the document in the medication room is assumed to have been an effort to provide an additional checkpoint for clinical staff

members securing medications. Without proper education on the value of the tool, similar situations as described in this case study may occur. An alternative to a “sheaf of papers” is using the originator’s document in poster form. The single-layer poster, which clearly identifies its purpose, provides an easy-to-read cross-reference of look-alike, sound-alike medication names. Transcultural nurses dealing with new cultural expectations may be at greater risk for miscommunication. Culture care theory suggests added considerations for cultural influences in patient care planning.18 Similarly, health care organizations should provide programs to help transcultural nurses assimilate the differences in clinical practices and interpersonal relationships. In many cultures it is not acceptable to question persons in authority (eg, physicians). Health care organizations should include components in the orientation programs stressing the importance of health care provider communications and the significance of patient advocacy. This case study does not state how long the RN had been in the United States or the length of time she had practiced in the current setting. A “mild language barrier” has been identified. This assessment should alert coworkers to potential discrepancies in interpretation of information and signal a pause when she attempts to verify directions. While this RN did attempt to reconfirm the medication ordered by showing it to the surgeon, the surgeon did not interrupt his or her activities to verify the vial name. To minimize confusion, the perioperative verbal order should include both brand and generic medication names and be reconfirmed by spelling out each name.2,8,16,17 After writing the order down, a verbal read-back of the initial intraoperative medication order should be performed with the prescribed dose verbalized by using a digit-by-digit (eg, “one-two,” not “twelve”) method. This verbal read-back also should have occurred during the transfer of the medication to the sterile field. 2,19

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Questions that could be explored to help understand the contributing factors for this near miss include the following. • What factors related to delegation did the perioperative registered nurse appeared to neglect in this near miss? • What steps could be taken to ensure that the allied health care provider is competent to assume the responsibility of completing the tasks delegated to him or her? Perioperative registered nurses rely on support personnel and allied health care providers to facilitate the delivery of safe patient care. When the registered nurse determines that a competent, unlicensed health care worker can safely perform an activity, he or she may delegate the task. The nurse retains accountability for the completion of the activity and any patient outcomes as a result of the act of delegation.20 Delegation of nursing tasks occurs within the clinical role, skill set, and documented competency of the individual assigned to the activity. Delegation must conform to applicable law, regulation, and accrediting agency standards.21 Support personnel should have the appropriate education and documented competency required to perform the assigned function.

The registered nurse in this situation deemed the allied health care provider competent to deliver medication packets to a patient ready for discharge. The case study does not provide enough information to determine if the medications were to be available at home or if the patient was to take the medications before departure. Without assuming the intent of the activity delegated, the discussion will focus on the apparent gap in the medication handling and administration process. It is apparent that the allied health care provider failed to accurately identify the patient receiving the medications. Before medications are passed to a patient, the patient should be identified by two separate identifiers to verify the intended person receives the intended treatment.2 The nurse in charge of the delegated task may have identified the patient by name, but it is unclear whether the allied health care provider was familiar with the standards for patient identification. Before handing the task over to the allied health care provider, a review of the identification process should have occurred to reinforce national safety initiatives to improve the accuracy in patient identification and to reinforce safe medication handling practices.2,5

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LESSONS LEARNED • Facilities should provide work environments that promote safe medication handling and administration (eg, lighted work stations, minimize distraction). • The circulating registered nurse and scrub personnel should audibly and visually verify the medication name, dose, strength when applicable, and expiration date from the manufacturer’s label before transfer of the medication onto the sterile field. • All medications need to be labeled. The circulating registered nurse and scrub personnel should verify that labeling on containers and medication transfer devices includes the medication name, strength when applicable, dose, and expiration date and time (if the medication will expire before completion of the intervention) before transferring medications to the sterile field. • Whenever a patient hand-off period occurs (eg, staff relief, shift-change, patient transfer) a comprehensive review of all patient care activities, including the identification of medications the patient has been taking or ones that will be used during the perioperative care period, must be completed. • Verbal medication orders will be provided in both generic and brand names. The person receiving the verbal order will write it down as soon as possible and verify it through a verbal read-back that includes the spelling of the medication name and the dose identified by a digit-by-digit process. • Two different identifiers are used to verify that the correct patient receives the correct medication or treatment. Patient allergies are communicated before medication is administered.

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Notes 1. Institute of Medicine, To Err Is Human: Building a Safer Health System, Committee on Quality of Health Care in America, ed L T Kohn, J M Corrigan, M S Donaldson (Washington, DC: National Academies Press, 2004). 2. “AORN guidance statement: Safe medication practices in perioperative settings across the life span,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2006) 321-327. 3. Institute of Medicine, Keeping Patients Safe: Transforming the Work Environment of Nurses, Committee on Work Environment for Nurses and Patient Safety, Board on Health Care Services, ed A Page (Washington, DC: The National Academies Press, 2004). 4. “Organizations release new tools for reducing medication errors,” (Dec 10, 2002) Institute for Safe Medication Practices, http://www. ismp.org/Tools/pathways.asp (accessed 17 May 2006). 5. “Joint Commission 2006 National Patient Safety Goals Implementation Expectations,” Joint Commission on Accreditation of Healthcare Organizations, http:// www.jointcommission.org/NR/ rdonlyres/DDE15942-8A19-46749F3B-C6AE2477072A/0/06_NPSG _IE.pdf (accessed 17 May 2006). 6. S C Beyea, ed, Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary, second ed (Denver: AORN, Inc, 2002) 103-104. 7. “Reporting of medical/heath care errors: A position statement from the Joint Commission, 2005,” Joint Commission International Center for Patient Safety, http://www. jcipatientsafety.org/show.asp?durki =9348&site=149&return=9808 (accessed 17 May 2006).

8. S C Becker, R W Hicks, Medication Errors in the Operating Room (Rockville, MD: United States Pharmacopeia, 2003). 9. “Neuromuscular blocking agents— Proposed labeling and packaging standards for medication error prevention,” USP Quality Review 72 (February 2000), US Pharmacopeia, http://www.usp. org/patientSafety/newsletters/ qualityReview/qr722000-0201.html (accessed 17 May 2006). 10. “Loud wake-up call: Unlabeled containers lead to patient’s death,” ISMP Medication Safety Alert (December 2, 2004) Institute for Safe Medication Practices, http://www.ismp.org/Newsletters /acutecare/articles/20041202.asp (accessed 17 May 2006). 11. Error Alert: Unlabeled Basins in Sterile Field, (media release, Dec 2, 2004) Institute for Safe Medication Practices, http://www.ismp.org/ pressroom/PR20041202.pdf (accessed 17 May 2006). 12. Joint Commission on Accreditation of Health Care Organizations, “Sentinel events—In memory of Ben: A case study,” Joint Commission Perspectives (March/April 1997). Also available at http://www.jointcommission.org /NR/rdonlyres/39B79D63-7336 -48E1-B2AD-632A2906F403/0/ March_April_1997_Perspectives.pdf (accessed 29 April 2006). 13. Curbing Medication Errors the Focus of National Campaign, (media release, June 20, 2005) AORN, Inc, http://www.aorn.org/ toolkit/safemed/pdf/NTOD%20 news%20release.pdf (accessed 17 May 2006).

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14. “Recommended practices for safe care through identification of potential hazards in the surgical environment,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2006) 547-553. 15. “Recommended practices for maintaining a sterile field,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2006) 621-628. 16. US Pharmacopeia, “Use caution— Avoid confusion,” USP Quality Alert 76 (March 2001) 1-6. Also available at http://www.usp.org/ pdf/EN/patientSafety/ qr762001-03-01.pdf (accessed 17 May 2006). 17. Joint Commission on Accreditation of Healthcare Organizations, “Look-alike, sound-alike drug names,” Sentinel Event Alert 19 (May 1, 2001). Also available at http://www.jointcommission.org/ SentinelEvents/SentinelEvent Alert/sea_19.htm (accessed 17 May 2006). 18. “Leininger’s Sunrise Enabler to Discover Culture Care,” M Leininger, 2004, http://ntpr.org/ groupee _files/attachments/ 1/0/4/104108801/104108801_ Leininger_Sunrise_Enabler_10. 2004.pdf?ts=44556085&key= A5442869384DB8AE68EA0F8BF9 D8BE7C&referrer=http%3A%2F %2Fntpr.org%2Fgroupee%2 Fforums%2Fa%2Fga%2Ful%2F62 3107513%2FLeininger_Sunrise_ Enabler_10.2004.pdf (accessed 17 May 2006).

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19. “Council recommendations to reduce medication errors associated with verbal medication orders and prescriptions,” (adopted February 20, 2001, revised February 24, 2006) National Coordinating Council for Medication Error Reporting and Prevention, http://www.nccmerp.org/council/ council2001-02-20.html (accessed 17 May 2006). 20. “Working with others: A position paper,” National Council of State Boards of Nursing, http://www. ncsbn.org/pdfs/Working_with_ Others.pdf (accessed 17 May 2006). 21. “Position statement on allied health care providers and support personnel in the perioperative practice setting,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2007) in press.