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Medication errors are the most common type of medical errors. A recent study found that medication errors and adverse drug events occurred in about half of all surgeries. This was the first study to look into the incidence of medication errors in the perioperative period. This study occurred at the Massachusetts General Hospital, which is considered one of the best hospitals in the country. It’s a 1,046-bed, tertiary care academic teaching hospital in Boston. Anesthesiologists and CRNAs conducted the study over an eight-month period.
Researchers observed 277 surgeries and witnessed 3,671 medication errors, or one in every 20 administrations. There were 193 observed errors, which is about 50% of all surgeries. About 80% of the errors, or 153 errors, were preventable. Two-thirds of the medication errors were serious and 2% were life threatening. Fortunately, none resulted in any patient deaths, even though three were classified as being potentially fatal.
One patient with a known penicillin allergy developed a rash after taking a similar drug. Another patient’s blood pressure dropped significantly, but the anesthesiologist and nurses failed to act. A nurse incorrectly set up an IV drip that was going wide open. There were many errors related to the wrong dose or an omitted dose. Surgeries lasting more than six hours resulted in a higher rate of error. One reason may be the hectic nature of the operating rooms where there may not be time to perform double checks.
Another observation was the failure to document the medication error. The CMS hospital CoPs requires that all medication errors be documented in the medical record, which must include a notation that shows a physician was made aware.
Evaluation of Perioperative Medication Errors and Adverse Drug Events; Karen C. Nanji, M.D., M.P.H.; Amit Patel, M.D., M.P.H.; Sofia Shaikh, B.Sc.; Diane L. Seger, R.Ph.; David W. Bates, M.D., M.Sc., AnesthesiologyNewly Published on 10 2015.
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