Study finds medication errors, adverse drug events in 1 out of 2 surgeries studied

http://www.eurekalert.org/pub_releases/2015-10/mgh-sfm101915.php

Public Release: 25-Oct-2015
Study finds medication errors, adverse drug events in 1 out of 2 surgeries studied
Massachusetts General Hospital

The first study to measure the incidence of medication errors and adverse drug events during the perioperative period - immediately before, during and right after a surgical procedure - has found that some sort of mistake or adverse event occurred in every second operation and in 5 percent of observed drug administrations. The study of more than 275 operations at Massachusetts General Hospital (MGH),

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"We found that just over 1 in 20 perioperative medication administrations resulted in a medication error or an adverse drug event," says Karen C. Nanji, MD, MPH, of the MGH Department of Anesthesia, Critical Care & Pain Medicine, lead author of the report. "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.

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Nanji explains that, while drug orders on inpatient floors go through a process in which they are checked several times by different providers - the ordering physician, pharmacist and nurses administering the medications - the rapidity with which the condition of patients in the operating room can change doesn't allow time for that sort of double- and triple-checking during surgical procedures. Although operating rooms at MGH and other hospitals have installed electronic documentation and bar-coded syringe labeling systems to reduce errors, in other patient care the measures that have cut errors areas have all started with a rigorous analysis of the incidence and type of errors that were occurring.

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Overall, it was determined that 124 of the 277 observed operations included at least one medication error or adverse drug event. Of the almost 3,675 medication administrations in the observed operations, 193 events, involving 153 medication errors and 91 adverse drug events, were recorded either by direct observation or by chart review. Almost 80 percent of those events were determined to have been preventable. One-third of the observed medication errors led to an adverse drug event, and the remainder had the potential to cause an adverse event. Of the adverse drug events that were recorded, 20 percent were not associated with a medication error.

The most frequently observed errors were mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patient's vital signs, and documentation errors. Of all the observed adverse drug events and the medication errors that could have resulted in patient harm - four of which were intercepted by operating room staff before affecting the patient - 30 percent were considered significant, 69 percent serious and less than 2 percent life-threatening; none were fatal. The overall medication error rate of around 5 percent was the same among anesthesiologists, nurse anesthetists and residents. Medication errors and adverse drug events were more common with longer procedures, especially those lasting longer than six hours and involving 13 or more medication administrations.

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