Medication Errors Occur In Close To Half Of All Surgeries

A study of more than 275 operations at Massachusetts General Hospital (MGH) revealed that almost half included at least one medication error or adverse drug event.

Lead author Dr. Karen C. Nanji, a Mass General anesthesiologist, said that mistakes can happen more often in surgical suites than in standard inpatient rooms because the fast pace of patient condition changes during surgery does not always allow for multiple medication checks prior to administration.

Previous studies showed that there were little to no known errors during surgeries, but these studies were self-reported data and were not as accurate as direct observation.

Even at a prestigious academic medical center like Massachusetts General Hospital in Boston, medication errors and adverse drug events prove problematic.

Two-thirds of the drug errors were categorized as “serious”, while 2 percent were considered life-threatening (though none of the patients died as a result). The pharmacist, ordering physician, and the nurse administering the medications all check the drugs and sometimes, time prevents their capability to double-check or triple-check the medication.

“This study is especially valuable because it looked in a detailed way into medication errors in the operating room, where numerous safety strategies used in other settings have not yet been adopted, and used trained observers to document these errors”, added study senior author David Bates, MD, MSc, of the Department of Medicine at Brigham and Women’s Hospital. Operating room staff intercepted four adverse drug events or medication errors before they affected the patient.

Researchers observed 225 anesthesia providers – including anesthesiologists, nurse anesthetists and resident physicians – during 277 operations conducted at the hospital from November 2013 through June 2014.

Researchers discovered that the most common type of mistakes committed were errors in labeling, overlooking to treat a problem related to the vital signs of a patient, errors in documentation and incorrect dosage. She noted in a press statement about the study showing that mistakes occur in half of all surgeries, there is definitely room for improvement to prevent perioperative medication mistakes, and “now that we understand the types of errors that are being made and their frequencies, we can begin to develop targeted strategies to prevent them”.

The study is just the latest focusing attention on medical errors and the need to reduce them since 1999.

In a report which will be issued in the journal Anesthesiology, researchers found that mistakes occurred in five percent of drug administrations and one in every 20 drug administrations have caused adverse effects to patients.

Dr. Katz, as reported by Philly, considered that the numbers resulting from the study are disturbing, although he said they are not surprising. As Nanji explained, surgical operations sometimes require quick decision making, and taking action without extremely careful consideration, because time is of the essence in such cases.