Overall, it was determined that 124 of the 277 observed operations included at least one medication error or adverse drug event. The paper’s researchers analyzed more than 275 procedures undertaken at Massachusetts General Hospital (MGH), uncovering that a third of the errors resulted in patients being harmed.
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In past studies, doctors rarely self-reported medication errors during surgery.
To conduct such an analysis for perioperative settings, four specially trained members of the research team observed 225 anesthesia providers – anesthesiologists, nurse anesthetists, and resident physicians – during 277 randomly selected operations conducted at the MGH from November 2013 to June 2014. 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. They found that 5 percent of drugs given improperly results in negative drug events. Worse still, 80 percent were preventable.
Sign up for our FREE E-Weekly for more coverage like this sent to your inbox! However, the study showing that half of all surgeries have a few type of medical mistake indicates that hospitals need to do more to improve safety.
They found that the most common mistakes made were wrong dosages being administered, symptoms indicated by vital signs of a patient going without untreated and medication labeling mistakes. “Now that we have a better idea of the actual rate and causes of the most common errors, we can focus in developing solutions to address the problems”, Nanji said in a Mass General press release.
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.
“In the operating room, things happen very rapidly, and patients’ conditions change quickly, so we don’t have time to go through that whole process, which can take hours”, Nanji said. Dr. Nanji explained that this has something to do with the dynamic and fast pace of the operating room. Since that time, medical professional have worked to improve safety using simple tools like checklists before, during and after a procedure or more sophisticated ones like electronic systems for prescribing and warning doctors about potential medication errors. Less than 2 percent of the errors (3) were deemed potentially life-threatening, but thankfully, the authors didn’t observe any fatalities.
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The study appears in Anesthesiology, the official journal of the American Society of Anethesiologists. “Our next step will be to design more comprehensive decision support to further reduce the incidence of errors in the perioperative setting”. They also considered chart data, patient history, and information from the hospital’s information management system to verify that observed mistakes were actually mistakes.
