Medical errors in surgeries common: US study
28 October 2015
About half of all surgeries involved some kind of medication error or unintended drug side effects, a new study conducted at one of the US' most prestigious academic medical centers had shown.
The rate, calculated by researchers from the anaesthesiology department at Massachusetts General (Mass General) Hospital who observed 277 procedures there, was startlingly high compared to those in the few earlier studies.
In those studies, mostly self-reported data from clinicians was used. The studies found errors to be exceedingly rare.
''There is a substantial potential for medication-related harm and a number of opportunities to improve safety,'' according to the new study, published in the journal Anesthesiology. Over a third of the observed errors led to some kind of harm to the patient.
Attention has been focused on reducing medical errors since 1999, when the Institute of Medicine identified them as a leading cause of death, killing at least 44,000 Americans a year - more than car crashes or breast cancer.
Since then, hospitals had attempted to improve safety during surgery with simple checklists to avoid lapses like operating on the wrong side of the body. Electronic prescribing systems that can warn doctors of potential medication errors had also been adopted.
However, mistakes at the intersection of medication and surgery ''have really not been studied in any systematic way,'' said Karen Nanji, an anaesthesiologist at Mass General and lead author of the new study.
According to the study, the mistakes included drug labelling errors, incorrect dosing, drug documentation mistakes, and / or not properly treating changes in a patient's vital signs during surgery.
The study found that in 124 of 277 surgeries, a medication error or adverse drug event was documented and of the 3,675 medication administrations (most patients receive more than one drug during surgery), 193 medication errors and adverse drug events were recorded, according to the Harvard researchers said.
Also almost 80 per cent of those events were determined to have been preventable.
"This is the first large-scale look at medication errors in the time immediately before, during and directly after surgery," said Nanji.
"But in my opinion, while there is much room for improvement, our results are not surprising," she added.
"In fact, it's very likely that this issue is even more problematic given that Mass General is a national leader in patient safety, and has gone out of its way to study this issue in order to improve outcomes," she suggested.