Current Health Care Problem or Issue


Throughout medical history, there has been a medical-related issue that collides with one of the core values of health care, “not harm.” Particularly, preventable medication errors in the operating room. An operating room is an environment where many things happen simultaneously with a multi-dimensional range of practitioners playing different roles. Medication errors can be inevitable at times. Medication usually changes hands several times before administration to the patient, increasing the risk for an error. According to Redman (2017), it is not always practical to have a surgeon stop operating to put in an electronic order for a medication they had not anticipated needing. However, it is a perioperative nurse’s responsibility to ensure they have gotten the order right before proceeding.

Elements of the Problem/Issue

In all areas of health care, the basic principle of “no harm” is universal. This factor brings multi-dimensional professionals in health care settings to work together for the patient’s utmost benefit. We can define safe surgery as ensuring minimal mistakes during pre, intra, and post-operative stages to protect the patient.

Medical error is a failure to acquire a desirable goal. It is crucial to avoid healthcare-related errors across the spectrum of all health care practitioners to ensure patient safety. As perioperative nurses, it is our responsibility o ensure medication orders are taken accurately. The perioperative nurse must obtain, prepare and dispense medication to the operative field. There is potential for errors to occur during each of these steps. For example, a surgeon or anesthesia provider will give a vernal order for a medication; the perioperative nurse’s responsibility is to ensure they have heard the order correctly before obtaining the medication. Interrupting a physician who is actively operating on a patient to clarify an order can be challenging but is necessary to prevent medication errors. Effective communication between health care practitioners is a vital factor to procedures having a successful outcome.

As a perioperative nurse and preceptor, I have seen nurses’ reluctance to interrupt a procedure to clarify an order. Providing an environment in which nurses are comfortable and confident with this step in the medication process is imperative to prevent potential errors. “Patient safety systems should focus on building a culture of safety that encourages communication, trust and honesty” (Kim et al., 2015).


As a perioperative nurse and member of the surgical team, I am specifically concerned about patient safety in this clinical setting. Perioperative nurses are well aware of the fact that medication errors constitute a substantial portion of medical errors that lead to adverse patient outcomes. The surgical team has to implement a wide range of tasks and function in a stressful environment due to potential emergencies (Göras et al., 2019). Healthcare practitioners must be committed to being an advocate for patient safety improvements associated with medication error elimination.

The context for Patient Safety Issues

Over 2% of reported sentinel events have been recognized to be directly linked to medication administration errors (Redman, 2017). Simultaneously, the cases that do not lead to serious adverse effects remain unreported, so the problem’s scope is considerably broader. The existing bulk of evidence suggests that these types of errors are preventable in most cases (Hauk, 2018; Litman, 2018; Redman, 2017). Moreover, clear guidelines and different kinds of policies are available to healthcare professionals (Burlingame, 2018). Although these standards are instrumental in minimizing medication administration errors, eliminating the problem has proved to be unattainable so far.

Populations Affected by Patient Safety Issues

As mentioned above, the problem’s scope is broad, and it affects many groups of people. People who have to undergo surgical procedures are vulnerable regardless of their age, socioeconomic status, or other characteristics (Litman, 2018). The surgical staff has to make numerous decisions based on circumstances that are often unique, and patients have no opportunity to ensure their safety in the setting of the operating room. Therefore, surgical teams must collaborate and communicate effectively, ensuring full compliance with the latest protocols and policies to ensure patients are protected.


Perioperative nurses should be at the front line to raise red flags by studying preoperative assessment forms to identify patient vulnerabilities. The nurse should communicate these vulnerabilities to other healthcare providers within the operating room. Lack of communication will lead to failure in achieving the patient’s expectations for the surgery. Quality of care is dependent on nurses speaking out to ambiguity that may be essential in preventing harm, Further research should be carried out to identify surgeons and other doctors’ attitudes towards disruptions during surgical procedures. To avoid errors, all surgical personnel should take precautions at all phases of the medication use cycle. Perioperative nurses serve as surgeon’s assistants. Before, during, and after surgery perioperative nurses must provide patient care. All roles combine to work hand in hand to ensure the nurse’s role streamlines smoothly without an incident. Therefore, perioperative nurses are the voice of the patient during surgery.


The most critical area for consideration associated with preventing medication errors (MEs) in a perioperative setting is concerned with preventable, observed, and potential adverse drug events (ADEs) (Nanju & Bates, 2017). To cover all categories of MEs and ADEs associated with them, communication between providers is essential. The proposed solution to avoid errors in medication at perioperative settings is concerned with effective communication in the specific context, with a variety of strategies required to enhance the quality of services provided to patients. To improve the safety of patients during surgical interventions, both communication within a team and the situational awareness of its members must be enhanced (Shitu et al., 2018). The role of each team member within the proposed setting should be acknowledged and detailed in other to provide correct, rapid, and effective healthcare service delivery. Effective communication patterns within which teams convey large data volumes in shorter time periods are essential for avoiding MEs and subsequent ADEs.


With the help of effective and cohesive communication between healthcare personnel, it is expected to implement several strategies aimed at reducing medication errors. The first strategy is ensuring that the language used in communication is appropriate, clear, and straightforward. It is vital that the staff uses the abbreviation and medical jargon that is common and understandable to all of them to avoid misunderstandings and issues with miscommunication. In addition to ensuring effective communication between nurses, there also will be situations in which healthcare professionals would explain the use of medication to their patients (Shitu et al., 2018). Overall, the foundation of a high-quality and patient-centered approach becomes essential.

The next strategy that should be implemented concerns the definition and understanding of professionals’ roles to provide rapid, effective, and life-saving health delivery services. Health care delivery is inherently complex and interdependent, which requires personnel to work together while also accounting for their responsibilities. Through teamwork, it is possible to manage complex work situations by breaking important staff assignments into separate tasks and delegating components of the work to nurses. Although, it is recommended to avoid the limitations of the industry that emphasize the division of labor and ignore the mechanisms of coordination and integration (Shitu et al., 2018). Overcoming the obstacles to effective collaboration includes advocating for active listening among healthcare providers, formulating care recommendations for a specific audience, and also providing visuals to enhance understanding.

The third strategy is concerned with appropriate team composition and task interdependence. Team composition is essential to consider because research findings point to the differences in attitudes about teamwork between colleagues in a surgical setting, including a variation in the perceptions about the ways in which conflicts should be resolved. Because of this, it is necessary to consider team composition as a basis of improvement (Rosen et al., 2019). For instance, interdisciplinary and interprofessional rounds within a surgical setting may include problem-solving and planning episodes, including nurses, physicians, surgeons, and other professionals. In addition, the team working in a perioperative setting should include pharmacists to provide the needed expertise about medications, thus helping to avoid medication errors. Overall, the extensive collaboration between healthcare personnel working in a perioperative setting is essential for reducing medication errors. Each team member should be aware of their roles while also ensuring precise and accurate communication to promote the understanding of how they should proceed in every situation.


Burlingame, B. L. (2018). Guideline Implementation: Medication Safety. AORN Journal, 107(3), 477–484. Web.

Göras, C., Olin, K., Unbeck, M., Pukk-Härenstam, K., Ehrenberg, A., Tessma, M. K., Nilsson, U., & Ekstedt, M. (2019). Tasks, multitasking and interruptions amonth the surgical team in an operating room: a prospective observational study. BMJ Open, 9(5), 1–12. Web.

Hauk, L. (2018). Avoiding errors when preparing medications in the perioperative setting. AORN Journal, 107(3), 9–11. Web.

Kim, F. J., Donalisio da Silva, R., Gustafson, D., Nogueira, L., Harlin, T., & Paul, D. L. (2015). Current issues in patient safety in surgery: a review. Patient Safety in Surgery, 9(25), 1–9. Web.

Litman, R. S. (2018). How to orevent medication errors in the operating room? Take away the human factor. British Journal of Anaesthesia: BJA, 120(3), 438–440. Web.

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Redman, D. D. (2017). Reducing Medication Errors in the OR. AORN Journal, 105(1), 106–109. Web.

Rosen, M., DiazGranados, D., Dietz, A., Benishek, L., Thompson, D., Pronovost, P., & Weaver, S. (2019). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. The American Psychologist, 73(4), 433-450. Web.

Shitu, Z., Hassan, I., Aung, M. M., Kamaruzaman, T. H., & Misa, R. M. (2018). Avoiding medication errors through effective communication in a healthcare environment. Movement, Health & Exercise, 7(1), 115-128.