The Critical Mistake: Incomplete Medication Reconciliation
The critical error in this scenario is incomplete medication reconciliation (Option A), as the patient's chronic diabetes and hypertension medications were not properly documented and continued during the perioperative period, representing a fundamental breakdown in ensuring continuity of the patient's home pharmacological treatments.
Why Medication Reconciliation is the Primary Error
The scenario describes a patient with chronic conditions (diabetes mellitus and hypertension) on medications who underwent surgery. The critical mistake occurs at the transition of care from admission through surgery to the postoperative ward. Preventing anesthesia errors related to chronic patient medications requires efforts that start upstream of the procedure, with strong involvement of healthcare professionals to ensure medication reconciliation using appropriate tools, including creation of a pharmaceutical record during the pre-procedural anesthesiologist visit 1.
The Perioperative Vulnerability
Surgical patients with chronic conditions are at particularly high risk during transitions of care, where medication discrepancies commonly occur at admission, during the procedure, and postoperatively 1.
Careful attention must be directed to risks related to managing and ensuring the continuity of each patient's pharmacological treatments, including medications taken chronically 1.
The admission to hospital is a critical transition point for continuity of care in medication management, and medication reconciliation can identify and resolve errors due to inaccurate medication histories 2.
The Scope of the Problem
Medication discrepancies are classified into four groups: no-longer taking, not in record, dosing issues, and direction issues—each placing patients at risk for medication-related problems 1.
Studies show that 41% of patients have one or more unintended discrepancies at admission, with the most common errors being omission of regularly used medications (76%) and incorrect dosages (16%) 2.
Approximately 4-6% of medication discrepancies are clinically relevant and place patients at risk for harm 1.
Why the Other Options Are Less Likely
Poor Postoperative Assessment (Option B)
While postoperative assessment is important, the scenario doesn't indicate any specific assessment failure. The patient received morphine, which is appropriate postoperative analgesia. The problem isn't what was assessed or given postoperatively, but rather what was omitted—the chronic medications that should have been reconciled and continued 1.
Pharmacy-Related Error (Option C)
A pharmacy error would imply the pharmacist made a mistake in dispensing or preparing medications. However, the scenario suggests a systems failure in the medication reconciliation process rather than a specific pharmacy dispensing error. The roles of all those potentially involved in managing chronic medications must be formally defined, including nurses and pharmacists, through medication reconciliation 1.
The Medication Reconciliation Process That Should Have Occurred
At Admission
An accurate list of the patient's home medications (diabetes and hypertension medications) should have been obtained using standardized approaches 2, 3.
This list should have been compared with admission medication orders to identify any unintended discrepancies 2.
The five rights rule should be applied: right medication, in the right dose, at the right time, via the right route, to the right patient 1, 4.
During the Perioperative Period
The pre-procedural anesthesiologist visit should have included creation of a pharmaceutical record documenting all chronic medications 1.
Decisions about which chronic medications to continue, hold, or modify perioperatively should have been explicitly documented 1.
At Transfer to Surgical Ward
Medication reconciliation should have been repeated when the patient transferred from the operating room to the surgical ward 1.
The chronic medications for diabetes and hypertension should have been reordered and continued postoperatively unless specifically contraindicated 1.
Clinical Consequences of This Error
Failure to continue chronic medications for diabetes and hypertension in the perioperative period can lead to:
Hyperglycemia or hypoglycemia if diabetes medications are omitted or incorrectly dosed 4.
Hypertensive crisis or inadequate blood pressure control if antihypertensive medications are discontinued 1.
Increased risk of adverse cardiovascular events in the postoperative period 1.
Common Pitfalls to Avoid
Assuming someone else performed medication reconciliation—this represents a handoff failure where each provider assumes another has addressed chronic medications 1.
Focusing only on surgical/anesthetic medications while neglecting chronic home medications—the perioperative period requires attention to both acute procedural needs and chronic disease management 1.
Incomplete medication histories at admission—studies show that 67% of medication histories contain at least one prescription error, with 22% having potential to cause significant patient harm 4.
Lack of communication between the surgical team, anesthesia, and the patient's primary care providers—medication reconciliation requires multidisciplinary involvement 1.