Medication errors, adverse drug events seen in half of surgeries

Just under 80 percent of the errors were judged to be preventable.
By Stephen Feller  |  Oct. 26, 2015 at 2:47 PM
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BOSTON, Oct. 26 (UPI) -- Researchers at Massachusetts General Hospital found a mistake or adverse event occurred during one out of every two surgeries and in five percent of drug administrations, according to a new study.

While medications are often triple or quadruple checked in normal hospital circumstances as they are passed from doctors to nurses for patients, during surgery there often is not time for that type of verification -- leading to inevitable errors.

Some operating rooms have electronic systems that allow for documentation and tracking of medications to reduce errors, said Dr. Karen Nanji, the lead author of the study.

"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, a researcher in the department of anesthesia, critical care and pain medicine at MGH, said in a press release. "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."

Researchers observed 225 hospital anesthesia providers -- anesthesiologists, nurses and doctors -- during 277 operations in 2013 and 2014. The researchers considered surgery to be from the time a surgical provider took responsibility of the patient until the patient either was brought to recovery or the intensive care unit. They also considered chart data, patient history, and information from the hospital's information management system to verify that observed mistakes were actually mistakes.

The researchers found that 124 of the 277 surgeries had at least one medication error or adverse drug event. Of the 193 surgical events researchers observed, 153 were medication errors and 91 were adverse events, with 80 percent of them preventable and one-third of them led to an adverse event.

"We already have an electronic anesthesia management and documentation system for medications, patient vital signs and other events occurring in the operating room," Nanji said. "Our next step will be to design more comprehensive decision support to further reduce the incidence of errors in the perioperative setting."

The study is published in the journal Anesthesiology.

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