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Perioperative patients are especially vulnerable to harmful medication errors due to poor communication during handoffs and lack of coordination throughout the surgical process, according to a recent report from the United States Pharmacopeia (USP).

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Researchers looked at more than 11,000 drug errors in perioperative settings, which included outpatient surgical suites, preoperative holding areas, operating rooms, and postanesthesia care units. Five percent of errors caused harm to patients, including four deaths. This percentage of harm is more than three times higher than the percentage of harm in other settings that USP tracks.


Children were at greater risk for harm in the perioperative setting. Almost 12% of drug errors involving children were harmful.


One researcher, Diane Cousins, RPh, noted that patients undergoing surgery often traverse a system of several departments within the hospital. "Even if located along a single hallway, these departments can be remarkably disconnected from one another," she said. "The fragmented system creates a high risk for harmful medication errors."


For more information about the report, A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005, visit the USP Web site at