Use of MEDMARX Datafor the Supportand Developmentof PerioperativeMedication Policy

Vivian M. Devine, PCNS, CNOR, RNa,*,Sandra C. Bibb, DNSc, RNb

KEYWORDS� MEDMARX � Perioperative � Medication� Policy � Safety � Database � Military

Perioperative evidence-based practice dependson synthesis of data from internal and externalbenchmarking.1 Development of perioperativemedication policy should be guided by synthesisof these data and by recommendations from perio-perative professional organizations and regulatoryagencies. However, limited evidence of this synthe-sis exists in the literature to guide policy develop-ment for safe medication practices for this criticalspecialty.2 Responding to this gap in knowledge,the Association of periOperative Registered Nurses(AORN) collaborated with United States Pharma-copeia (USP) to analyze perioperative medicationerror reports from the MEDMARX database. Thisdatabase contains a unique classification systemfor medication errors that supports coding of all re-cords of medication errors according to the extentof harm, to include potential errors causing noharm. These invaluable data have the capability toguide the development of medication policy in thehigh-risk perioperative environment through identi-fication of causative factors and trends. Yet, todate, there has been no descriptive summary of if,or how MEDMARX data are currently being usedto support the development of perioperative medi-cation policy. The purpose of this research study

The views of the authors are their own and do not reflUniversity of the Health Sciences, the United States Navya United States Navyb Department of Health Systems, Risk, and ContingencyHealth Sciences, Graduate School of Nursing, 4301 Jones* Corresponding author.E-mail address: cdrviv@yahoo.com (V.M. Devine).

Perioperative Nursing Clinics 3 (2008) 317–325doi:10.1016/j.cpen.2008.08.0141556-7931/08/$ – see front matter. Published by Elsevier

was to describe how MEDMARX data are beingused to support the development and revision ofpopulation health medication policy across theperioperative continuum.

REVIEWOF LITERATURE

Population health focuses on improving healthoutcomes, eliminating health disparities, and re-ducing health care costs for a particular group ofpeople.3–6 Central to improving the outcome forsurgical patient populations is the reduction of pa-tient safety risk factors. The United States patientsafety epidemic was documented in the Instituteof Medicine’s (IOM) report in 1998.7 This landmarkreport indicated that 98,000 deaths occurred eachyear as a result of medical errors. More recently,the IOM report from November 2003, entitled ‘‘Pa-tient Safety: Achieving A New Standard For Care,’’calls for a unified national health information infra-structure as a requirement to make patient safetya standard of care.8

Patient Safety Risk

With medical mistakes ranking sixth as the leadingcause of death in American hospitals today, the

ect the views or opinions of the Uniformed Services, or the Department of Defense.

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Devine & Bibb318

urgency exists to identify probable causativefactors.9 According to recent USP data, a large por-tion of medical mistakes in the hospital setting arecomprised of medication errors, with 235,000 er-rors reported in the 2003 MEDMARX annual sum-mary report10 and 950,000 adverse drug eventsreported in MEDMARX as of January 2006.11

In an immediate effort to decrease patient safetyrisk in hospitals across America, the United StatesCongress approved a billion dollar patient safetyinitiative.12 Shortly after Congress endorsed theseinitiatives for all health care facilities, a plethora ofliterary and Web-based resources emerged. Someof these initiatives assessed and evaluatedpractices at both the unit and hospital level, withincreased analyses of systems within health carefacilities.

The MEDMARX Database

In 1998, USP created a central depository foranonymous medication error reporting througha subscription service, namely the MEDMARXdatabase. Since then, annual reports have beenpublished identifying common trends and causa-tive factors among like facilities and similar groupsof patients. By analyzing the trends and factorscontributing to medication mistakes in various fa-cilities, a clearer picture of the problem areas hasemerged. Once identified, these causative factorscould then be reduced or eliminated throughevidenced-based interventions, to maximize theeffectiveness of safe medication practices.

USP owns another older and less-used data-base for voluntary reporting of errors, named theMedication Error Reporting (MER) database. Thisdatabase contains roughly one-tenth the datasetsreported to MEDMARX. While it is a free, anony-mous service, MER lacks the number of reportsneeded to generate reports of trends from itsusers. Although the number of medication errorsshould not be the sole criteria for determininga useful database, it does afford the analysis ofcausative factor trends.4 Therefore, the MED-MARX database is preferred over the MER data-base for secondary analysis. As stated in theUSP E-newsroom, ‘‘This third annual report, Sum-mary of Information Submitted to MEDMARX inthe Year 2001: A Human Factors Approach toMedication Errors, is the most comprehensivecompilation of medication error data submittedby hospitals and health systems nationwide.’’13

Unsafe Perioperative Practices

The operating room and postanesthesia care unitshare unsafe medication administration practices,including nonspecific policies for unit stock

medications, communication of verbal orders,and written case card preference sheets. MED-MARX data have identified these specific unsafepractices in all phases of the perioperative contin-uum throughout the literature. Once the cause isknown, systems involved in the unsafe processcan be evaluated, and gaps identified, to furtherdevelop or modify existing medication policy.2,14

The National Patient Safety Goals (NPSG)15 havealso been created as a direct response to reportedmedication errors and medical mistakes, raisingawareness to increase patient safety efforts. In2005, the NPSG added reconciliation of medica-tions across the continuum of care as their eighthspecific goal.12 This goal provides guidelines forhow to achieve their recommendation, whichstates all patients will have a complete list of med-ications that they are currently taking on their chartat all times, with this information communicatedthroughout each phase of their care.16 Other med-ication recommendations provided by this organi-zation include improving infusion pump safety,safety of using all medications, and effectivenessof communication. This last goal is further brokendown into recommending standardized abbrevia-tions, acronyms, and symbols, as well as verifyingorders through verbal or telephone orders.12,15

The professional organizations, AORN andAmerican Society for PeriAnesthesia Nurses (AS-PAN), have assisted perioperative advanced prac-tice nurses (APNs) with identification of gapswithin their practice environment, and have pro-vided standardized tools to improve those patientsafety, risk-prone areas. The ‘‘wrong side/site’’tool kit was developed by AORN17 in response tothe Joint Commission on Accreditation of Health-care Organizations (JCAHO) patient safety goal re-quirement. Additionally, the kit contained a policytemplate for all facilities to use, in an effort to stan-dardize best practice policy. With the success ofthis interdisciplinary initiative, AORN recentlydeveloped a safe medication tool kit to increasestandardization of medication practices acrossthe perioperative continuum.

An Underused Asset

MEDMARX data are being used for performanceimprovement projects on the surgical population,revealing the database as a user-friendly tool.2,18

Perioperative APNs could benefit from a compre-hensive list of such studies using the MEDMARXdatabase for a quick review of existing trends inmedication errors. From this list, perioperativenurses could envision the body of evidence-basedresearch studies available and integrate thisknowledge into future medication policy and best

Medication Policy 319

medication practices.19 Additionally, medicationerror trends that have not been explored, thus re-quiring further study, will be easily identified asgaps in the current body of knowledge. It is onlythrough the exploration of these gaps that the sur-gical patient population can achieve a healthy,safe outcome.

Significant gaps relating to medication errorcauses have been identified over the past 6 years,yet there exists no collection of interventions thathave been taken to correct these causative factors,as identified in medication policy documents in theliterature.2,9,10,14,20–25 Perioperative APNs are of-ten consulted to update policy based on the lateststandards, while incorporating evidence-basedfindings in the defense of modified policy, accord-ing to Heitkemper and Bond.26 A list of studies inthe literature using secondary analysis of the MED-MARX database to support perioperative medica-tion policy, and assist in the identification offuture research needed, would be an invaluable as-set for the perioperative APN.27,28

The study described in this article was con-ducted using the methodologic approach anddata collection tools piloted in a study conductedby Bibb and colleagues6 to identify and describe

Parent Study: Identification and De

Population Health Resear

Conceptual

Framework Measureme

PHDID, C

Manifest Content

Analysis

Descriptive

Frequencies

Curren

PHDID =PopulaDatabase IdentiDescription datasheetCDAS = ClinicaAssessment Su

Fig.1. Conceptual framework for MEDMARX policy docum

clinical databases and datasets used to supportdevelopment of population health programs andpopulation health policy (Fig. 1). The study de-scribed in this paper focused specifically on theuse of the MEDMARX data in the support and de-velopment of medication policy in the periopera-tive setting.

Conceptual Definition—PerioperativeMedication Safety Policy

The definition of perioperative medication policyincludes standards set by regulatory agencies:JCAHO, the Food and Drug Agency (FDA), andthe Department of Defense Health and HumanServices (DoDHHS), in conjunction with recom-mendations from professional organizations(AORN and ASPAN), state requirements, and facil-ity instructions, which guide the development ofevidence-based medication practices in the perio-perative environment.1,4,29

Operational Definition—PerioperativeMedication Safety Policy

Unit-based adjuncts, such as instructions, proto-cols, explanations, and checklists, are used to op-erationalize a facility’s perioperative medication

scription of Clinical Databases for

ch and Program Design

nt Tools:

DAS

Key Word

Search

Knowledge

Experience

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tion Healthfication and collection

l Databaservey

ent study.

Devine & Bibb320

policy. Specific examples of the aforementionedinclude laminated medication safety drug cardswith preapproved calculations listed, preapprovedsurgeon’s preference cards with desired ‘‘formu-lary’’ medications specific for the patient andcase listed, and point-of-care pharmacist access.

Specific Aims

The specific aims of this study were:

TabSu

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0

1

5

5

19

1

1

0

0

0

37

To describe the use of the MEDMARX data-base in the development and revision ofpopulation health medication policy acrossthe perioperative continuum;

To identify a list of population health medica-tion policies that have been developed orrevised, as a result of secondary data anal-ysis of the MEDMARX database;

To create a list of population health medica-tion policies that could be developed andsupported, using the MEDMARX data-base; and

To generate a list of population health medi-cation research topics that could be ad-dressed for future study by perioperativeadvanced practice nurses.

METHODS

The research design for this study was descriptive.The methodologic approach was adopted froma study by Bibb and colleagues, in which a system-atic search of the literature using the Cumulative In-dex to Nursing and Allied Health Literature(CINAHL) and the National Library of Medicine’ssearch service (PubMed) bibliographic databases,covering the years 2003 and 2004, was conductedto locate completed population health studies

le1mmation of key words used for bibliographic searches

mber of Hits Number of Abstracts Saved Key

3 ‘‘ME

0 ‘‘ME

1 ‘‘ME

3 ‘‘ME

0 ‘‘ME

9 ‘‘ME

0 ‘‘ME

0 ‘‘ME

0 ‘‘ME

0 ‘‘ME

0 ‘‘ME

16 Tota

conducted by means of secondary analysis of ex-isting clinical or administrative data. Key wordsassociated with theoretic definitions of clinicaldatabase, secondary analysis, military healthcare, federal health care, and population healthprograms, policy, and research were used to locateabstracts. Healthy People 2010 leading health indi-cators (physical activity, overweight and obesity,tobacco use, substance abuse, responsible sexualbehavior, mental health, injury and violence, envi-ronmental quality, immunization, access to care)and key words ‘‘safety’’ and ‘‘deployment health’’were also used to locate abstracts. A systematicconfirmatory process and exclusion algorithmwere used to determine which abstracts and corre-sponding articles to include in the study. A data col-lection template was used to guide extraction ofdata from each article. Descriptive statistics andmanifest content analysis were used to analyzeand summarize data. A total of 52 completed pop-ulation health studies were included in the analysis.Twenty datasets were identified. One of the data-sets identified was the MEDMARX database. Iden-tification of the MEDMARX dataset was associatedwith the key words ‘‘secondary analysis’’ and‘‘safety.’’ Location and analysis of published stud-ies associated with secondary analysis of datafrom the MEDMARX data set and used in the devel-opment of population health medication policy forthe perioperative setting was the focus of the anal-ysis for the study described in this article.

After the MEDMARX dataset was identified asthe dataset for the focus of this study, a new sys-tematic search of the literature was conducted toidentify articles or policy documents that usedthe MEDMARX database in research, programs,or development of policy or policy-like documents.

Words

DMARX’’ and ‘‘secondary analysis’’

DMARX’’ and ‘‘military health policy’’

DMARX’’ and ‘‘policy’’

DMARX’’ and ‘‘safety’’

DMARX’’ and ‘‘patient safety’’

DMARX’’ and ‘‘medication errors’’

DMARX’’ and ‘‘adverse drug reactions’’

DMARX’’ and ‘‘perioperative patient safety’’

DMARX’’ and ‘‘perioperative medication policy’’

DMARX’’ and ‘‘operating room policy’’

DMARX’’ and ‘‘intraoperative medication policy’’

l articles16, minus 6 exclusions 510 articles in study

Box1Articles used in study

1. Beyea SC, Hicks RW, Becker SC. Medicalerrors in the OR–a secondary analysis ofMEDMARX. AORN Journal 2003;77(1):22.

2. Beyea SC, Kobokovich LJ, Becker SC, et al.Medication errors in the LDRP: identifyingcommon errors through MEDMARX Report-ing. AWHONN Lifelines 2004;8(2):130–40.(4 ref)

3. Cousins DD. Developing a uniform report-ing system for preventable adverse drugevents. Clin Ther 1998;20(Suppl C):C45–58.

4. Cowley E, Williams R, Cousins D. Medicationerrors in children: a descriptive summary ofmedication error reports submitted to theUnited States Pharmacopeia. Current Thera-peutic Research 2001;62(9):627–40. (2 ref)

5. Hicks RW, Becker SC, Krenzischeck D, et al.Medication errors in the PACU: a secondaryanalysis of MEDMARX findings. Journal ofPeriAnesthesia Nursing 2004;19(1):18–28.(17 ref)

6. Hicks RW, Cousins DD, Williams RL. Selectedmedication-error data from USP’s MED-MARX program for 2002. Am J Health SystPharm 2004;61(10):993–1000.

7. Jones KJ, Cochran G, Hicks RW, et al. Trans-lating research into practice:voluntary re-porting of medication errors in criticalaccess hospitals. Journal of Rural Health2004;20(4):335–43.

8. Niccolai CS, Hicks RW, Oertel L, et al.Unfractionated heparin: focus on a high-alert drug. Pharmacotherapy 2004;24(8 Pt 2):146S–55S.

9. Nosek RA Jr, Bourg MP, Pereira I. Standardiz-ing medication error reporting using Med-MARx. Legal Medicine 2002;7p, 2p. (8 ref)

10. Santell JP, Hicks RW, McMeekin J, et al. Med-ication errors: experience of the UnitedStates Pharmacopeia (USP) MEDMARX re-porting system. J Clin Pharmacol 2003;43(7):760–7.

Medication Policy 321

Data Collection Process

Thirty-five key words, based on the conceptualdefinitions for the study described in this article,in combination with the word ‘‘MEDMARX,’’ wereused in a search algorithm to identify articles anddocuments (Table 1). A systematic confirmatoryprocess and exclusion algorithm were used to de-termine which abstracts and corresponding arti-cles to include in the study. Systematic search ofthe literature from January 1, 1998 through July31, 2005 retrieved 37 articles describing the useof MEDMARX data. Nineteen of the articles werediscovered through CINAHL, and 18 through theNational Library of Medicine (PubMed) biblio-graphic databases.

The abstracts or summaries of these articleswere printed to verify that they met the inclusioncriteria. However, because of insufficient informa-tion in the summaries or abstracts to complete theinclusion algorithm, full articles were retrieved todetermine which abstracts met inclusion criteria.

Six articles were excluded from the study be-cause they did not meet the inclusion criteria.The remaining 10 articles were included in thisstudy and were analyzed for content (Box 1).

Description of Data Analysis

A data collection template was used to guideextraction of qualitative and quantitative datafrom each article. Quantitative data were codedand entered into SPSS version 12.0 for statisticalanalysis. Descriptive statistics were used to de-scribe and summarize quantitative data. Manifestcontent analysis was used to analyze qualitativedata and to identify themes related to use ofMEDMARX data to support policy development.

RESULTSPresentation of Results

The first aim of this study was to describe the useof the MEDMARX database in the developmentand revision of population health medication pol-icy across the perioperative continuum. None ofthe 10 articles included in the study contained ev-idence that MEDMARX data were being used tocreate or revise medication policy.

The second aim of this study was to identify a listof population health medication policies that havebeen developed or revised, as a result of second-ary data analysis of the MEDMARX database.Again, none of the 10 articles included in the studycontained evidence that MEDMARX data were be-ing used to create or revise medication policy.

A summary table of all articles used in the study,with main content summarized, illustrates the gap

of written evidence to support policy creationand modification based on MEDMARX findings(Table 2).

The third aim was to create a list of populationhealth medication policies that could bedeveloped and supported using the MEDMARXdatabase. To create this table, themes wereextracted from all of the articles using manifestcontent analysis, using phrases that depicted spe-cific medication policies throughout the articles(Box 2).3,6 Generation of a list of population healthmedication research topics that could be ad-dressed for future study by perioperative APNswere identified in table format (Table 3).

Table 2Recommendations from the literature formedication policies that could be developed using theMEDMARXdatabase

Literary Recommendations for FuturePerioperativeMedication Policy Development

No. of SupportingArticles From Box1

1. High alert medication protocol (2nd verifier) 1, 2, 4–6, 8, 10

2. Competency evaluation of staff regarding medication policy 1–4, 7, 8, 10

3. Automated medication delivery system(decreasing reliance on floor stocked meds)

1, 2, 6, 7, 10

4. Technological System based improvements(Bar coding, built-in safety alert software, ComputerizedPrescriber Order Entry (CPOE), medication error reporting)

3, 6, 7, 9, 10

5. Use Point of Care Pharmacist model 1, 2, 4, 5, 7

6. Standardized acronyms, abbreviations, and medication doses 1, 2, 4, 6

7. Preprinted standard order forms with approved dosingnomograms

2, 5, 8

8. Telephone order/verbal order verification protocol withprocedural steps listed

1, 8

9. Medication labeling policy of all meds (including sterile field) 1

10. Increased communication during transferof patient (medication reconciliation)

1

Devine & Bibb322

DISCUSSIONDiscussion of Major Findings

The major gap in the literature regarding policychange or modification supports this study’s argu-ment for an increased awareness of the use of theMEDMARX database to influence medicationsafety policy in the perioperative setting. This evi-dence-based change should be at the forefront ofevery APN’s agenda for their individual specialty,

Box 2Policies that could be developed usingMEDMARX data

Standardized medication ordering system

� Computerized surgeon’s preference cards with ancase cart (surgical supplies)

� Built in safety alerts

Standardized medication delivery system

� Automated dispensing system to decrease floormedication

Standardized medication administration system

� Second verifier required for all pediatric and high� Surgeon preference cards as dr. order for all periop

Pharmacy integration in all perioperative practices

� Preapproval of all unit formularies for floor stock� Pharmacy involvement needed to mix medications� A point of care pharmacist is available

to immediately decrease the patient safety riskthrough policy development. Some of therecommended policy themes are simple and canbe integrated into existing policy immediately,with the more complex recommendations of sys-tem change requiring interdisciplinary resourceplanning.

Research topics that were identified from theliterature consistent of areas within the APN’sspecialty that require further study. Without this

automatic pharmacy order placed upon ordering

stock for operating room and bar coding all

alert medications: label all medications.erative medication

and prepare high alert medications

Table 3Research topics that could be developed usingMEDMARX data

Research Topic ThemesSpecifics Regarding Necessityof Research

Perioperative specialty unitscould benefit from research

Causative data for medicationerrors and near misses inspecialty areas are needed

Identifies trends for harmful or nearmiss medication errors, and practicesthe following policy (ie, same daysurgery, operating room holdingarea, and gastrointestinal/endoscopy units)

Operating Rooms couldbenefit from research

Operating rooms are high riskmedication safety areas

Focuses on quality assurance monitorsregarding perioperative policystatements, with observation anddocumentation data to support thatthe policy is being practiced

Participating MEDMARXsubscribers could benefitfrom research

Benchmark-like institutions Compares and contrasts medicationerrors in similar healthcare facilitiesto identify causes and examinemedication policies

Medication Policy 323

additional research, perioperative medicationpolicy cannot be modified to best reflect safemedication practices for the surgical patient.Therefore, the safety of future surgical patientsreceiving medication rests on the APNs in the peri-operative milieu and the decisions they make inmodifying medication policy based on evidence-based findings.

Increased research is needed to identifyspecific causative factors of near misses to pro-actively change systems at risk to preventmedication errors from occurring. With 95% ofall of the medication error reports in theMEDMARX database being ‘‘non-harm’’ cate-gories, this database is the only one that shouldbe used in the identification of preventable med-ication errors.10

Identification of Limitations

Limitations of this study included researchersubjectivity and bias, as there was only one re-searcher. Additionally, there was a small samplesize of 10 articles.

Implications for Nursing

APNs are equipped with the skills required to an-alyze secondary data from nationally recognizeddatabases for medication errors. They are alsoeducated in recognizing areas of further researchthat are needed to expound the evidence-basedknowledge in their nursing specialty.26,30 TheMEDMARX database contains a plethora of rich,untapped data that are waiting for someonewith the expertise to recognize the immense

potential in making the health care industry a saferplace to administer medications. The time is now,the place is here, the database is MEDMARX, andthe person is the advanced practice nurse. Thisis the perfect recipe for preventing futuremedication errors for the surgical patients oftomorrow.

Recommendations for Future Research

A list of population health medication researchtopics was developed that could be used byperioperative advanced practice nurses. Thislist can further the evidence-based knowledgeof current medication policy’s impact in the sur-gical setting. Additionally, Nosek’s9 article stated,‘‘The Department of Defense piloted a programin December of 2000 using MEDMARX to stan-dardize medication error reporting across theMilitary Health System (MHS),’’ and was goingto report the benefits. The absence of literary ev-idence in this regard provides a gap in knowl-edge, which warrants further research todetermine the effect of the MEDMARX databaseon medication error reporting across all militaryhealth care facilities. Further analysis of the useof the MEDMARX database in subscribing facili-ties through a survey would be beneficial. Addi-tionally, further studies exploring the existenceof other medication error reporting databaseswould add to the current knowledge base onperioperative medication safety.

In conclusion, literature does not support themodification or creation of medication safetypolicy based on MEDMARX database findings.

Devine & Bibb324

The MEDMARX database is the largest, nationallyrecognized medication error reporting tool avail-able to subscribers to include the Military HealthSystem Patient Safety Program, a Department ofDefense program. These valuable data areunderused in effecting change of unsafe medica-tion policy in health care systems across the globeand should be immediately integrated into futurepolicy decisions, with the acknowledgment as a re-source. Further secondary analysis of MEDMARXdata, specific to causative factors of medicationerrors occurring in the perioperative setting, isneeded to provide the sound evidenced-basedknowledge on which to develop and update safemedication policy.

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