Research reveals medication errors made during surgery.
What kinds of mistakes are the researchers referring to?
“The mistakes included drug labeling errors, incorrect dosing, drug documentation mistakes, and/or failing to properly treat changes in a patient's vital signs during surgery,” according to CBS news.
The Harvard researchers found that a medication error or adverse drug event occurred in 124 of 277 surgeries. They also saw that of the 3,675 medication administrations (the majority of patients receive more than one drug during surgery), 193 medication errors and adverse drug events were recorded. How many could have been prevented? Researchers said almost 80 percent.
Doctors from Massachusetts General Hospital led the study. Dr. Karen Nanji, an assistant professor of anesthesia at Harvard Medical School in Boston, commented on the study.
She said, “This is the first large-scale look at medication errors in the time immediately before, during and directly after surgery. But in my opinion, while there is much room for improvement, our results are not surprising.”
She also said that 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 their surgical outcomes.
Dr. Nanji, who is also with the department of anesthesia, critical care and pain medicine at Massachusetts General Hospital, reported her team's findings on October 25 in the journal Anesthesiology.
How can hospitals prevent these errors?
The study authors said that rigorous safety checks commonly in place across many hospital settings are often loosened or bypassed in the surgical environment, when fast-moving events and changing circumstances can require quick decisions and fast action.
The researchers looked at surgeries done in 2013 and 2014.
CBS news reports, “All drugs and drug errors were recorded (or gleaned from medical charts) covering the time a patient entered a pre-operative area until they were out of surgery and in either a recovery room or an intensive care unit. The result: more than 5 percent of the time, drugs were given in error or negative drug events were observed.”
Researchers found that two-thirds of the drug errors were categorized as serious, and out of that, 2 percent were considered life threatening.
Dr. John Combes, chief medical officer of the American Hospital Association in Washington, D.C.,
“Hospitals across the country are constantly looking for ways to improve patient care. This study provides important insights and highlights areas of focus for further action and study. By learning the root cause of such errors, hospitals and health systems can work to provide the best patient experience for each episode of care.”
Dr. David Katz, director of the Yale University Prevention Research Center in New Haven, Conn., said, ‘awareness of problems is where all solutions begin’.