New Study Shows Alarmingly High Rate of Medication Error in Surgeries

According to a new study published in Anesthesiology, almost half of today’s surgeries result in medication error.

The study tracked more than 275 surgical procedures at Massachusetts General Hospital (MGH)—a Harvard-affiliate institution and a national leader in patient safety—and is unique in its efforts to measure errors occurring during the preoperative, operative, and postoperative stages. The results showed that a medication error occurred in one of every two surgeries observed.

“These numbers are disturbing, but not surprising,” remarked Dr. David Katz of Yale University’s Prevention Research Center, in a CBS News article. Comparing surgical teams to professional athletes, he explained “medical care is [also] intense, and often rather complex. Many parts are in motion, the stakes are high, and there is often time pressure.”

In another article, Karen Nanji, anesthesiologist at MGH and lead researcher on the study, offered a positive perspective when faced with the results, stating that MGH has “a long history of being very open with mistakes in order for themselves and other centers to learn from them.”

So What Exactly Did We Learn?

Nanji’s study shows that a majority of the errors made were errors in medication—in fact, it was calculated that an error or adverse drug event was made in one of every 20 drug administrations. These include, but are not limited to, mistakes in labeling, dosage, documentation, and adverse drug effects on the patient.

However, this issue is not new to those in the medical field. In 1999, the Institute of Medicine identified medical errors as the leading cause of death among Americans, and since then, an increased push for patient safety has occurred with the use of electronic prescribing systems, double-checking prescriptions by pharmacists and nurses before administration, and other safeguards that warn against medication errors.

OR Environment More Challenging

Still, when medicine meets surgery, things begin to get more complicated. Nanji explained, “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.”

As disconcerting as this may seem, Nanji assures that “patients don’t need to go into surgery thinking that they’re going to have lasting permanent harm every second operation.” Although all errors found could potentially cause harm, in some instances the observed effects were changes in vital signs or elevated risks of infection. Only three of the cases were classified as life-threatening, and no patients died because of the observed mistakes.

Majority of Errors Preventable

Perhaps the most interesting take-away from the study is that 80% of the medication errors were considered “preventable.” Many of these errors were the result of mislabeled medicines. With many of the medications being clear liquids, without proper labeling it becomes easy to inadvertently administer the wrong one to a patient.

Katz suggests an integration of human effort with technological safeguards, saying “we need a multi-layered defense, involving careful humans backing one another up, and automatic systems backing up the humans.” Efforts are being made to better build this technological defense. For example, Omnicell’s Anesthesia Workstations now integrate with the Codonics Safe Label System, which helps reduce and prevent medication errors due to improper labeling.

Learning from the Study

Nanji is optimistic. “Prior to our study,” she stated, “the literature on perioperative medication error rates was sparse and consisted largely of self-reported data, which we know under-represents true error rates. Now that we have a better idea of the actual rate and causes of the most common errors, we can focus on developing solutions to adequately address the problems.”

See a video of the Anesthesia Workstation with Codonics Safe Label System.

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