Perioperative Pharmacology:

Antibiotic Administration

2.0

LINDA WANZER, MSN, RN, CNOR; BRADLEE GOECKNER, MSN, RN, CNOR;
RODNEY W. HICKS, PhD, RN, FNP-BC, FAANP, FAAN

www.aorn.org/CE

ABSTRACT
Accurate and timely administration of antibiotics is a crucial element of perioperative patient care but, often, pharmacologic implications of antibiotics are overlooked
or misunderstood. Preventable medication errors that involve antimicrobials occur throughout the perioperative continuum. Examples of errors associated with
antimicrobial use include omitted doses, duplicate doses, incorrect doses, and
antimicrobial products given to patients with preexisting allergies. Perioperative
nurses can contribute to safe antibiotic administration through education and
improved communication. Perioperative managers should ensure that practitioners have access to standards for antibiotic administration and accurate information and assistive technologies. Numerous resources, including measurement
tools and published guidelines, are available to support adherence to surgical site
infection prevention requirements and assist in ensuring effective and safe
perioperative antibiotic use. AORN J 93 (March 2011) 340-348. AORN, Inc,
2011. doi: 10.1016/j.aorn.2010.08.026
Key words: medication safety, standards for medication safety, medication-use
process, safe medication use, perioperative antibiotic administration.

Editors note: This is the third in a series of articles on perioperative pharmacology. The first article was published in the January 2011 issue of
the Journal.

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t is Monday morning and Nurse D reports to

the preoperative holding area to greet the first
patient of the day, who is scheduled for a diagnostic knee arthroscopy. Nurse D reviews the
standard orders for this relatively routine procedure, which include an order for the standard orthopedic preoperative prophylactic antibiotic: a
one-time order for 1 g cefazolin to be administered on call to the OR. She notes that the patient
is only allergic to penicillin so she begins the antibiotic infusion at the appropriate time. Minutes later,
after the patient has transferred from the gurney to
the OR bed, she notes that the patient has a systemic rash, and the patient begins to complain that
doi: 10.1016/j.aorn.2010.08.026

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PERIOPERATIVE ANTIBIOTICS
his chest feels tight. Is it possible that this patient is
one of the 10% of patients with a history of penicillin allergy who has a cross-hypersensitivity to betalactam antibiotics? Nurse D stops the antibiotic
infusion and notifies the surgeon and anesthesia professional of the situation.
Cefazolin is one of the most common, highvolume antimicrobial agents used in the perioperative services, but it has pharmacologic implications that are often overlooked or misunderstood.
An antibiotic that is not administered properly or
is inappropriate for the procedure or patient could
have the opposite effect of that which is desired
and leave the patient with an untoward outcome.
The term prophylactic originates from the
Greek word prophulaktikos, which means advanced guard,1 which corresponds with the overall goal of administering preoperative antibiotics,
that being to guard the patient from contracting a
surgical site infection (SSI). Providing credence
to this activity is the centuries-old medical tenant
first and foremost do no harm.2 Accurate and
timely administration of antibiotics is a critical
element of perioperative patient care. The routine
and seemingly benign act of administering preoperative antibiotics, however, may have created a
complacent attitude among surgical team members
that, if allowed to go unchecked, may leave the patient vulnerable to a health care-associated infection.

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doses, duplicate doses, incorrect doses, and antimicrobial products given to patients with preexisting allergies.4
The definition and medication-error category
index established by the National Coordinating
Council for Medication Error Reporting and Prevention defines at what point the medication error
becomes harmful to the patient (Table 1). Harm is
defined as causing death or temporary or permanent impairment of body function or structure that
necessitates intervention.3 These interventions

TABLE 1. Medication Error Category

Index1
Category*

Definition

Circumstances or events that have the

capacity to cause error
An error occurred but the error did not
reach the patient
An error occurred that reached the patient
but did not cause patient harm
An error occurred that reached the patient
and required monitoring to confirm that
it resulted in no harm to the patient and/
or required intervention to preclude
harm
An error occurred that may have
contributed to or resulted in temporary
harm to the patient and required
intervention
An error occurred that may have
contributed to or resulted in temporary
harm to the patient and required initial
or prolonged hospitalization
An error occurred that may have
contributed to or resulted in permanent
patient harm
An error occurred that required
intervention necessary to sustain life
An error occurred that may have
contributed to or resulted in the
patients death

B
C
D

ERRORS INVOLVING
ANTIMICROBIAL USE
It is important to remember that any medication
error is a preventable event that may cause harm
to the patient while the medication is in the control of the health care professional.3 Preventable
medication errors that involve antimicrobial use
within the entire perioperative continuum (ie, outpatient surgery, preoperative holding area, OR,
postanesthesia care unit) and across the age span
of the perioperative population (ie, pediatric,
adult, older adult) occur more often than the perioperative community might intuitively believe.4-6
Examples of antimicrobial errors include omitted

H
I

* Categories A through D are classified as nonharmful; categories E

through I are classified as harmful.
1. NCC MERP Index for categorizing medication errors. National
Coordinating Council for Medication Error Reporting and Prevention.
http://www.nccmerp.org/aboutMedErrors.html. Accessed December
3, 2010.

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TABLE 2. Top Five Most Commonly Reported Products Associated With Perioperative
Medication Error by Clinical Area
Products

Comments

Outpatient surgery
Cefazolin
Midazolam
Morphine
Hydrocodone/APAP
Vancomycin

488
100
96
90
82

14.7
3.0
2.9
2.7
2.5

Based on 2,979 records, 3,323 selections, and 384 unique products reported

Preoperative holding area2

Cefazolin
Vancomycin
Levofloxacin
Midazolam
Cefoxitin

159
39
22
19
18

22.0
5.4
3.1
2.6
2.5

Based on 631 records, 719 selections, and 139 unique products reported

Operating room3
Cefazolin
Fentanyl
Morphine
Midazolam
Heparin

571
294
193
150
143

15.4
7.9
5.2
4.0
3.9

Based on 3,298 records, 3,703 selections, and 343 unique products reported

Postanesthesia care unit4

Morphine
Meperidine
Cefazolin
Hydromorphone
Fentanyl

582
215
210
200
147

17.6
6.5
6.3
6.0
4.4

Based on 2,874 records, 3,312 selections and 366 unique products reported

1. Table 1-12. Most commonly reported products involved in medication errors by population in outpatient surgery. In: MEDMARX Data Report: A Chartbook
of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:36.
2. Table 2-8. Most commonly reported products in preoperative holding area medication errors by population. In: MEDMARX Data Report: A Chartbook of
Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:56.
3. Table 3-8. Most commonly reported products involved in operating room medication errors by population. In: MEDMARX Data Report: A Chartbook
of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:79.
4. Table 4-8. Most commonly reported products involved in postanesthesia care unit medication errors by population. In: MEDMARX Data Report: A
Chartbook of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:103.

may include monitoring the patients condition, a

change in therapy, or active medical or surgical
treatment.3,4 To avoid harm, appropriate use of
antimicrobials throughout all phases of the
medication-use process across the entire patient
age span and throughout the perioperative continuum of care needs to be reinforced to help ensure
patient safety.
The most comprehensive review to date of
perioperative medication error data can be found
in the US Pharmacopeias 2006 MEDMARX
Chartbook of Perioperative Medication Errors.4
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The review examined 3,773 errors in accordance

with the variables of the National Coordinating
Council for Medication Error Reporting and Prevention Taxonomy.3 The analysis highlighted antimicrobial agents as the most commonly reported
classification of medication involved in perioperative medication errors.4
Cefazolin was the most commonly reported
medication involved in perioperative medication
errors in three (outpatient surgery, preoperative
holding area, OR) of the four clinical areas (Table
2). Although specifics related to the extent of

PERIOPERATIVE ANTIBIOTICS

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TABLE 3. Cefazolin Associated With Medication Error by Clinical Area

Clinical Area

488

14.7%

5.2%

Comments

Outpatient surgery unit

Overall (Category A-I)1

Harmful (Category E-I)2

Based on 2,979 records, 3,323 selections, and 384 unique products

Based on 87 records, 97 selections, and 52 unique products

Preoperative holding area

Overall (Category A-I)3

Harmful (Category E-I)4

159

22.0%

Based on 631 records, 719 selections, and 139 unique products

12.5%

Based on 21 records, 22 selections, and 16 unique products

Operating room

Overall (Category A-I)5

571

15.4%

Harmful (Category E-I)6

25

9.1%

Based on 3,298 records, 3,703 selections, and 343 unique products

Based on 239 records, 274 selections, and 96 unique products

Postanesthesia care unit

Overall (Category A-I)7

Harmful (Category E-I)8

210

6.3%

Based on 2,874 records, 3,312 selections, and 366 unique products

1.5%

Based on 171 records, 199 selections, and 57 unique products

1. Table 1-12. Most commonly reported products involved in medication errors by population in outpatient surgery. In: MEDMARX Data Report: A Chartbook
of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:36.
2. Table 1-13. Most commonly reported products involved in harmful (categories E-I) errors by population in outpatient surgery. In: MEDMARX Data
Report: A Chartbook of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of
Patient Safety; 2006:37.
3. Table 2-8. Most commonly reported products in preoperative holding area medication errors by population. In: MEDMARX Data Report: A Chartbook of
Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:56.
4. Table 2-9. Most commonly reported products involved in harmful (categories E-I) medication errors in preoperative holding area by population. In:
MEDMARX Data Report: A Chartbook of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the
Advancement of Patient Safety; 2006:57.
5. Table 3-8. Most commonly reported products involved in operating room medication errors by population. In: MEDMARX Data Report: A Chartbook
of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:79.
6. Table 3-9. Most commonly reported products involved in harmful (categories E-I) operating room errors by population. In: MEDMARX Data Report: A
Chartbook of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:80.
7. Table 4-8. Most commonly reported products involved in postanesthesia care unit medication errors by population. In: MEDMARX Data Report: A
Chartbook of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006:103.
8. Table 4-9. Most commonly reported products involved in harmful (categories E-I) postanesthesia care unit errors by population. In: MEDMARX Data
Report: A Chartbook of Medication Error Findings from Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of
Patient Safety; 2006:104.

harm associated with these errors may be difficult

to ascertain in some situations, the report also
identifies cefazolin as the most commonly reported medication that resulted in patient harm in
the OR (Table 3).4 Anecdotally, in the OR, cefazolin was the medication most reported to be associated with patient harm across the pediatric,
adult, and older adult patient populations.4 In the
preoperative holding area, cefazolin was the second most reported medication involved in medication errors that resulted in patient harm, with an
associated incidence of harm of 12.5%.4 These
findings are consistent with findings from other
examinations of products associated with medica-

tion errors throughout the perioperative continuum

of care.5-10
The medication errors associated with antimicrobial use can occur in any phase of the medicationuse process to include prescribing, transcribing
(eg, documentation), dispensing, or administering.
The perioperative medication error literature,
however, indicates that 50% to 60% of all perioperative medication errors occur during the administration phase of the medication-use process.58,10-13 Applying this statistic to the administration
of antimicrobials suggests that half or more of
antibiotic administrations involve an error. The
administration phase is the point at which the
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medication and the patient intersect and the medication imposes its pharmacologic effect. Health
care providers, such as physicians, RNs, and anesthesia professionals, are generally involved in
this phase of the medication-use process; therefore, it is paramount for these health care providers to understand the intricacies of antimicrobial
administration.
NURSING IMPLICATIONS
Perioperative nurses have many opportunities to
contribute to safe antibiotic administration. For
example, perioperative nurses are in a prime position to ensure that the right amount of the right
product is administered at the right time. As routine as it may seem, there are instances in which
prescribed antibiotics are never administered because the antibiotic
is not activated in the piggy-back container,
is hung and connected to the patients IV
but is not started, or
is hung and started but with the tubing not
actually connected to the patients IV.

puterized documentation screens. The goal is to

have workable forms that facilitate and document nursing care. Perioperative documentation
must be readily available to all health care providers throughout the continuum of care, especially if subsequent doses are to be scheduled
or timed based on the time of administration of
the first dose.
The US Pharmacopeias 2006 MEDMARX
Chartbook of Perioperative Medication Errors
provides numerous recommendations to prevent
medication errors unique to each clinical area
within the perioperative continuum of care.
Although not an exhaustive list, the following
recommendations may be applicable strategies
to help prevent medication errors that pertain to
antibiotics. Perioperative managers should ensure that

These errors may occur because of a lack of

knowledge of newer antibiotic supply technology,
breaks in communication (eg, during shift
changes), or confusion over who is responsible
for starting the antibiotic. Perioperative nurses can
help prevent all of these problems through education and improved communication.
Perioperative nurses must be aware that pediatric patients may require different doses than
adults, depending on the age of the pediatric patient. The perioperative nurse should use appropriate weight-based conversion tables to ensure
that the child receives an appropriate amount of
antibiotic for his or her weight and age. Allergy
information should be readily available to all
nurses, and perioperative nurses should confirm
the patients allergies again just before administering any medication, including antibiotics.
Nurses also can contribute to the design of
preprinted order forms and support the information technology department in designing com344

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documentation standards for antibiotic administration have been established and

implemented;
a sufficient number of staff members are
available to administer antimicrobial agents in
a timely fashion, including validation that the
piggy-back was properly activated;
satellite pharmacy support has been expanded if possible so that medications are
reviewed and are readily available and prepared within the area where they are being
administered;
the time-out standard is expanded to ensure
review of the preference card and confirmation
of medication directions and patient allergies;
strategies have been developed to ensure that
medications, especially antimicrobial agents,
are administered at the correct time;
health care providers have access to accurate
patient information, standardized dose charts,
and/or assistive technologies with proper
medication calculations and formulations, including pediatric doses;
communication between health care providers is
clear and includes confirmation of responsibility

PERIOPERATIVE ANTIBIOTICS
for administration of preoperative antibiotics,
transferring medications to the sterile field, and
labeling of all medications on the field.4
PERFORMANCE MEASUREMENT
DATA AND TOOLS
Health care providers must also be aware of the
many requirements, mandates, and standards associated with antimicrobial agent administration to
ensure safe and effective use of antimicrobials for
patients entering the perioperative continuum of
care. Documentation of appropriate prescribing,
dispensing, and administering of antimicrobials is
crucial to achieving the goals set by the Joint
Commission, Centers for Medicare and Medicaid
Services (CMS), and Centers for Disease Control
and Prevention (CDC) to reduce SSIs and enhance safe medication use for patients who enter
the health care system.14
The Joint Commissions goal of promoting
health care organizations quality performance
initiatives is a continuous, data-driven process
that focuses on actual outcomes of care. Since
1997, organizations can demonstrate quality activities and measures through the ORYX program,
the Joint Commissions performance measurement
and improvement initiative. In 2002, this initiative
evolved into the collection of specific data on
core performance measures that were closely
aligned with those identified by the CMS. The
2002 initiative shift toward core performance
measures coupled with the desire to minimize
duplication in data collection efforts resulted in a
decision by these two organizations in 2004 to
align current and future performance measures
that were common to both. These standardized
common core measures included Surgical Infection Prevention performance measures, which
transitioned to the Surgical Care Improvement
Project (SCIP) in 2006 and are currently integrated into the priority focus process used by the
Joint Commission during the accreditation process.15,16 In partnership with numerous national
organizations focused on reducing surgical com-

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plications, this program requires all health care

organizations that desire accreditation to select at
least three core indicators from a predetermined
list from which to gather and analyze data, initiate improvements, and report findings to the Joint
Commission on a quarterly basis. For the OR, the
three core measures that are most appropriate to
track and report are
postoperative complications: track and report
the number of patients who develop one of the
following complications:
central nervous system deficit,
peripheral nerve deficit,
acute myocardial infarction, or
cardiac arrest within two postoperative days;
intrahospital mortality: track and report the
number of patients who die while in the hospital within two postoperative days; and
surgical infection prevention: track and report
antibiotic use to ensure that
antibiotics are given within one hour before surgical incision,
appropriate antibiotics are administered, and
antibiotics, once initiated, are stopped
within 24 hours after surgery.16

An example of how perioperative managers

can meet the requirement for tracking and reporting data related to surgical site outcomes is presented in Table 4. Examples are given to describe
what should be measured,
the goal of the measurement,
the data collection plan, and
an example of an electronic tool from the Institute of Healthcare Improvement that can be
used to facilitate the process of collecting and
aggregating the data.17-20

Comparing SCIP core measurement data with

performance data provides the perioperative
manager with a mechanism by which to measure
internal processes and quality improvement
initiatives while demonstrating accountability for
enhanced quality of surgical care related to
SSIs.
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TABLE 4. Guidelines to Achieve Joint Commission ORYX Surgical Infection Prevention Metrics
Supporting the Surgical Care Improvement Project
ORYX/Surgical Infection Prevention
Track the frequency of the elements below and report to the Joint Commission on a
quarterly basis
Antibiotic selection
Formula

____ (#) of surgical patients who received the appropriate prophylactic antibiotic type consistent
with published guidelines divided by the total ____ (#) of surgical procedures requiring
prophylactic antibiotics

Goal

Threshold: 100% compliance of antibiotic selection consistent with published guidelines for surgical
procedures (eg, Center for Medicare & Medicaid Services, Centers for Disease Control and
Prevention)

Data collection plan

Prospective data to be captured on all patients receiving prophylactic antibiotics

Improvement
tracker/tool(s)

Percent of surgical cases with appropriate selection of prophylactic antibiotic. Institute for
Healthcare Improvement.
http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/Measures/SSIPercent
AppropriateAntibiotics.htm. Accessed December 14, 2010.

Prophylactic antibiotic initiation

Formula

Time antibiotics were initiated:

Within 1 hour before incision for most surgical procedures
Within 2 hours before incision for vancomycin
Completed before tourniquet inflation
Initiated when umbilical cord is clamped during a cesarean delivery

Goal

Threshold: 100% compliance of on-time prophylactic antibiotic administration achieved for all
procedures

Data collection plan

Prospective data to be captured on all patients receiving prophylactic antibiotics

Improvement
tracker/tool(s)

Percent of surgical cases with on-time prophylactic antibiotic administration. Institute for Healthcare
Improvement.
http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/Measures/
PercentCasesOnTimeProphylacticAntibioticMeasure.htm. Accessed December 14, 2010.

Prophylactic antibiotic discontinued after 24 hours

Formula

____ (#) of patients who received prophylactic antibiotics that were discontinued within 24 hours
divided by the total ____ (#) of patients who received prophylactic antibiotics

Goal

Threshold: 100% compliance of prophylactic antibiotics being discontinued within 24 hours after
the surgical procedure

Data collection plan

Prospective data to be captured on all patients receiving prophylactic antibiotics

Improvement
tracker/tool(s)

Percent of surgical patients who received prophylactic antibiotics after antibiotics were
discontinued within 24 hours of surgery. Institute for Healthcare Improvement.
http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/Measures/PercentofPatients
withAntibioticsDiscontinuedwithin24Hours.htm. Accessed December 14, 2010.

BEST PRACTICES FOR PREVENTING SSIs

In 2009, a new component of the Joint Commissions National Patient Safety Goal 7 was
implemented to help reduce patients risk of
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contracting a health care-associated infection.

This new element specifically focused on best
practices for preventing SSIs and had a oneyear phase-in period with full implementation

PERIOPERATIVE ANTIBIOTICS
expected by January 1, 2010. The elements of
performance for this goal closely mirror the
three core indicators for SSI prevention within
the SCIP, with the addition of performance
measures that target organizational systems and
education.14
To fulfill the elements of performance, facilities are urged to develop formal hospital policies
that meet or exceed regulatory requirements by
using evidence-based standards (eg, CDC, CMS).
It is expected that periodic risk assessments for
SSIs, inclusive of compliance monitoring and
evaluation of prevention efforts, will be initiated
and a process will be developed to disseminate
SSI rate data and prevention outcome measures to
the health care team.
Several education requirements that are focused
on SSIs, health care-associated infections, and the
importance of SSI prevention accompany National
Patient Safety Goal 7. To satisfy SCIP goals,
perioperative managers should implement educational programs for newly hired employees and
annual training targeted specifically to health care
workers involved in surgical procedures. In addition, organizations should implement an education
program for patients and family members before
all surgical procedures.
GUIDELINES TO SUPPORT SSI
PREVENTION REQUIREMENTS
In 1999, as part of an Infection Control Advisory
Committee of the CDC, Mangram et al21 published guidelines that outline principles for administration of antimicrobial prophylaxis for surgical
practice. These guidelines include
identification of surgical procedures that benefit from the use of antimicrobial prophylaxis,
the agent of choice for select surgical
procedures,
preoperative timing of administration duration
of use, and
21
discontinuation of antimicrobial prophylaxis.

This document provides perioperative practitioners with the framework on which to build poli-

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cies and procedures and develop monitors for

compliance, thus fulfilling the expectations of
quality monitoring and reporting.
The Specifications Manual for National Hospital Inpatient Quality Measures is another tool that
perioperative practitioners can use to support data
collection and analysis related to SSI prevention
for the SCIP. This publication is a collaborative
effort from the CMS and the Joint Commission as
a means to standardize national hospital quality
measures.22 Within this document, practitioners
can access algorithms that outline the antimicrobial prophylaxis process as well as tables that
support the selection of the correct antibiotic for
specific surgical procedures.
CONCLUSION
When meeting the patient and beginning the nursing care process, perioperative nurses should appreciate that the care they provide helps to ensure
that the patient does not experience a medication
error and can possibly prevent an SSI. Perioperative nurses should understand and participate in ongoing monitoring of antimicrobial use and understand that numerous resources are available to assist
in effective perioperative antibiotic use to ensure
optimal patient outcomes. Not adhering to the standards for antibiotic use in the perioperative setting
could result in an untoward patient outcome. Perioperative nursing actions also are crucial in helping the
health care organization meet the requirements for
performance measures and thus contribute to a successful accreditation visit.
Editors note: ORYX is a registered trademark
of the Joint Commission, Oakbrook Terrace, IL.
The views expressed are those of the authors and
do not reflect the official policy or position of the
Uniformed Services University of the Health Sciences, the Department of the Defense, or the US
Government.
References
1.

Definition of prophylactic. MedicineNet.com. http://

www.medterms.com/script/main/art.asp?articlekey
11902. Accessed November 22, 2010.

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2.

3.

4.

5.

6.

7.
8.

9.

10.

11.

12.

13.
14.

15.

16.

17.

18.

348

Vol 93

Greek medicine: the hippocratic oath. National Library

of Medicine. http://www.nlm.nih.gov/hmd/greek/
greek_oath.html. Accessed November 22, 2010.
What is a medication error? National Coordinating
Council for Medication Error Reporting and Prevention.
http://www.nccmerp.org/aboutMedErrors.html. Accessed November 22, 2010.
Hicks RW, Becker SC, Cousins DD. MEDMARX
Data Report: A Chartbook of Medication Error Findings from Perioperative Settings from 1998-2005.
Rockville, MD: USP Center for the Advancement of
Patient Safety; 2006.
Wanzer L, Hicks R. Medication safety within the perioperative environment. In: Fitzpatrick J, Stone P, Hinton Walker P, eds. Annual Review of Nursing Research.
Vol 24. New York, NY: Springer Publishing Company;
2007:127-155.
Wanzer L, Hicks R, Goeckner B, Cole L. A focused
review: perioperative safe medication use. Perioper
Nurs Clin. 2008;3:305-316.
Beyea SC, Hicks RW, Becker SC. Medication errors in
the day surgery setting. SSM. 2003;9:65-76.
Beyea SC, Hicks RW, Becker SC. Medication errors in
the ORa secondary analysis of Medmarx. AORN J.
2003;77:122-134.
Fasting S, Gisvold SE. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J
Anaesth. 2000;47:1060-1067.
Hicks RW, Becker SC, Krenzischeck D, Beyea SC.
Medication errors in the PACU: a secondary analysis of
MEDMARX findings. J Perianesth Nurs. 2004;19:
18-28.
Jenson LS, Merry AF, Webster CS, Weller J, Larsson
L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004;
59:493-504.
Webster CS, Merry AF, Gander PH, Mann NK. A prospective, randomised clinical evaluation of a new
safety-oriented injectable drug administration system in
comparison with conventional methods. Anaesthesia.
2004;59:80-87.
Wheeler SJ, Wheeler DW. Medication errors in anaesthesia and critical care. Anaesthesia. 2005;60:257-273.
Accreditation Program: Hospital National Patient
Safety Goals. The Joint Commission. http://www
.jointcommission.org/assets/1/18/July_2010_NPSGs_
Scoring_HAP2.pdf. Accessed December 14, 2010.
Facts about ORYX. The Joint Commission. http://
www.jointcommission.org/AccreditationPrograms/
Hospitals/ORYX/facts_oryx.htm. Accessed November
22, 2010.
Performance measurement initiatives: Surgical Care
Improvement Project core measure set. The Joint Commission. http://www.jointcommission.org/Performance
Measurement/PerformanceMeasurement/SCIPCore
MeasureSet.htm. Accessed December 14, 2010.
Measures: surgical site infections. Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/
PatientSafety/SurgicalSiteInfections/Measures. Accessed
December 14, 2010.
Percent of surgical cases with appropriate selection
of prophylactic antibiotic. Institute for Healthcare Improve-

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19.

20.

21.

22.

ment. http://www.ihi.org/IHI/Topics/PatientSafety/
SurgicalSiteInfections/Measures/SSIPercentAppropriate
Antibiotics.htm. Accessed December 14, 2010.
Percent of surgical cases with on-time prophylactic antibiotic
administration. Institute for Healthcare Improvement.
http://www.ihi.org/IHI/Topics/PatientSafety/Surgical
SiteInfections/Measures/PercentCasesOnTimeProphylactic
AntibioticMeasure.htm. Accessed December 14, 2010.
Percent of surgical patients who received prophylactic
antibiotic after antibiotics were discontinued within 24
hours of surgery. Institute for Healthcare Improvement.
http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSite
Infections/Measures/PercentofPatientswith
AntibioticsDiscontinuedwithin24Hours.htm.
Accessed December 14, 2010.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention
(CDC) Hospital Infection Control Practices Advisory
Committee. Am J Infect Control. 1999;27:97-134.
Performance measurement initiatives: current specification manual for national hospital quality measures. The
Joint Commission. http://www.jointcommission.org/
performancemeasurement/performancemeasurement/
currentnhqmmanual.htm. Accessed November 22,
2010.

Linda J. Wanzer, MSN, RN, CNOR,

COL(Ret), is the director of the Perioperative
Clinical Nurse Specialist Program and assistant
professor of nursing at the Uniformed Services
University of the Health Sciences, Graduate
School of Nursing, Bethesda, MD. COL
Wanzer has no declared affiliation that could
be perceived as posing a potential conflict of
interest in the publication of this article.
BradLee Goeckner, RN, MSN, CNOR, LCDR,
NC, USN, is a perioperative clinical nurse specialist and directorate of surgical services at
NAVMEDCEN, San Diego, CA. LCDR
Goeckner has no declared affiliation that could
be perceived as posing a potential conflict of interest in the publication of this article.
Rodney W. Hicks, PhD, RN, FNP-BC,
FAANP, FAAN, is a nurse researcher and consultant, Lubbock, TX. Dr Hicks has no declared affiliation that could be perceived as
posing a potential conflict of interest in the
publication of this article.

EXAMINATION
CONTINUING EDUCATION PROGRAM

2.0

Perioperative Pharmacology:
Antibiotic Administration

www.aorn.org/CE

PURPOSE/GOAL
To educate perioperative nurses about perioperative antibiotic administration.

OBJECTIVES
1. Explain the purpose of preoperative antibiotic administration.
2. Explain how appropriate use of antimicrobials helps ensure patient safety.
3. Identify antimicrobial agents administered in the perioperative area that have a
high risk for error.
4. Discuss the medication-use process.
5. Describe the Surgical Care Improvement Project (SCIP).
6. Identify resources that can be helpful in supporting adherence to surgical site
infection (SSI) prevention requirements.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS
1. The overall goal of administering preoperative
antibiotics is to guard the patient from contracting
an SSI.
a. true
b. false
2. To help ensure patient safety, appropriate use of
antimicrobials should be reinforced
1. across the entire age span (ie, pediatric, adult,
older adult).
2. throughout all phases of the medication-use
process.
3. throughout the perioperative continuum of care
(ie, outpatient surgery, preoperative holding
area, OR, postanesthesia care unit).
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 1, 2, and 3
AORN, Inc, 2011

3. ___________ was the most commonly reported

medication involved in perioperative medication
errors in outpatient surgery, the preoperative
holding area, and the OR.
a. Cefoxitin
b. Cefazolin
c. Levofloxacin
d. Vancomycin
4. Fifty percent to 60% of perioperative medication
errors occur during the _____________ phase of
the medication-use process.
a. administration
b. dispensing
c. prescription
d. transcription
5. The dispensing phase is the point at which the
medication and the patient intersect and the medication imposes its pharmacologic effect.
a. true
b. false
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March 2011

Vol 93

CE EXAMINATION

No 3

6. According to the SCIP, the core measures most

appropriate to track and report in the OR are
1. intrahospital mortality within two postoperative
days.
2. postoperative complications.
3. surgical infection prevention.
4. venous thromboembolism prophylaxis.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4
7. The goals of the SCIP requirements to track specific elements and report to the Joint Commission
on a quarterly basis include that
1. antibiotic selection is consistent with published
guidelines for surgical procedures.
2. antibiotics are administered on time in 100%
of procedures.
3. prophylactic antibiotics are discontinued within
24 after surgery on surgical patients 100% of
the time.
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 1, 2, and 3
8. Comparing SCIP core measurement data with
performance data
1. demonstrates accountability for enhanced quality of surgical care related to SSIs.
2. is required for Medicare reimbursement.
3. provides the perioperative manager with a
mechanism by which to measure internal processes and quality improvement initiatives.

a. 1 and 2
c. 2 and 3

b. 1 and 3
d. 1, 2, and 3

9. To satisfy National Patient Safety Goal requirements and SCIP goals, education about SSIs
should be
1. directed exclusively to surgeons and anesthesia
professionals.
2. implemented for newly hired health care providers involved in surgical procedures.
3. provided annually for health care workers involved in surgical procedures.
4. implemented on an organizational level for
patients and their family members before all
surgical procedures.
a. 1 and 2
b. 3 and 4
c. 2, 3, and 4
d. 1, 2, 3, and 4
10. The Infection Control Advisory Committee of the
Centers for Disease Control and Prevention published guidelines for administration of antimicrobial prophylaxis for surgical practice that include
1. identification of surgical procedures that benefit from the use of antimicrobial prophylaxis.
2. the agent of choice for select surgical
procedures.
3. preoperative timing of administration duration
of use.
4. discontinuation of antimicrobial prophylaxis.
a. 1 and 2
b. 3 and 4
c. 2, 3, and 4
d. 1, 2, 3, and 4

The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell
have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.

350

AORN Journal

LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM

2.0

Perioperative Pharmacology:
Antibiotic Administration

his evaluation is used to determine the extent to

which this continuing education program met your
learning needs. Rate the items as described below.

OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Explain the purpose of preoperative antibiotic
administration. Low 1. 2. 3. 4. 5. High
2. Explain how appropriate use of antimicrobials
helps ensure patient safety.
Low 1. 2. 3. 4. 5. High
3. Identify antimicrobial agents administered in the
perioperative area that have a high risk for
error. Low 1. 2. 3. 4. 5. High
4. Discuss the medication-use process.
Low 1. 2. 3. 4. 5. High
5. Describe the Surgical Care Improvement Project. Low 1. 2. 3. 4. 5. High
6. Identify resources that can be helpful in supporting adherence to surgical site infection prevention requirements.
Low 1. 2. 3. 4. 5. High
CONTENT
7. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
8. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High

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9. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No
10. Will you change your practice as a result of
reading this article? (If yes, answer question
#10A. If no, answer question #10B.)
10A. How will you change your practice? (Select all
that apply)
1. I will provide education to my team regarding
why change is needed.
2. I will work with management to change/implement a policy and procedure.
3. I will plan an informational meeting with physicians to seek their input and acceptance of
the need for change.
4. I will implement change and evaluate the effect of the change at regular intervals until the
change is incorporated as best practice.
5. Other:
10B. If you will not change your practice as a result
of reading this article, why? (Select all that
apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make a
change.
4. Other:
11. Our accrediting body requires that we verify the
time you needed to complete the 2.0 continuing
education contact hour (120-minute) program:

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center
approves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this
activity for relicensure.

Event: #11006; Session: #4059 Fee: Members $10, Nonmembers $20

The deadline for this program is March 31, 2014.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each
applicant who successfully completes this program can immediately print a certificate of completion.

AORN, Inc, 2011

March 2011

Vol 93

No 3 AORN Journal

351