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Medication Errors More Common Than Expected in Surgical Procedures

SAN DIEGO – Hospital seeking to decrease medication errors and adverse drug events need to put their surgical suites under scrutiny.

That’s according to a study, presented at the recent ANESTHESIOLOGY 2015 conference in San Diego and published online by the journal Anesthesiology, which found that some sort of mistake or adverse event occurred in every second operation and in 5% of observed drug administrations.

Considering that the study of more than 275 operations was at Massachusetts General Hospital (MGH), a leader in healthcare quality, study authors advise that other hospital take a close look at their surgical procedures.

"We found that just over one in 20 perioperative medication administrations resulted in a medication error or an adverse drug event," said lead author Karen C. Nanji, MD, MPH. "Given that Mass General is a national leader in patient safety and had already implemented approaches to improve safety in the operating room, perioperative medication error rates are probably at least as high at many other hospitals.”

For the analysis, the research team observed 225 anesthesia providers – anesthesiologists, nurse anesthetists, and resident physicians – during 277 randomly selected operations conducted at from November 2013 to June 2014. Every medication administration was documented from the time a provider took responsibility for a patient in the preoperative area until the patient arrived in the recovery room or intensive care unit. The observers were especially alert for any medication errors, defined as any type of mistake in the process of ordering or administering a drug, or adverse drug event that caused harm or injury to a patient, whether or not it was caused by an error. The team also conducted chart review.

Results indicate that 124 of the 277 observed surgeries included at least one medication error or ADR. Of the almost 3,675 medication administrations in the observed operations, 193 events, involving 153 medication errors and 91 ADRs were recorded either by direct observation or by chart review. Almost 80% of the events were determined to have been preventable.

Study authors note that one-third of the observed medication errors led to an ADR, with the remaining having that potential. Yet, 20% of the ADRs were not associated with medication error.

Errors most frequently observed were:

  • mistakes in labeling, incorrect dosage
  • neglecting to treat a problem indicated by the patient's vital signs
  • failure to document correctly.

With 30% of the errors considered significant, 69% serious and less than 2% life-threatening, none were fatal. Error rates were similar among anesthesiologists, nurse anesthetists and residents but more common with longer procedures, especially those lasting more than six hours and involving 13 or more medications, according to the results.

"While the frequency of errors and adverse events is much higher than has previously been reported in perioperative settings, it is actually in line with rates found in inpatient wards and outpatient clinics, where error rates have been systematically measured for many years," Nanji said. "We definitely have room for improvement in preventing perioperative medication errors, 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."

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