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Hospitals Often Make Medication Errors in Surgery

Half of all operations involved some kind of drug error in study at elite medical center

In the operating room, it is very difficult to go through multiple medication-check processes, and a study at Massachusetts General Hospital has found that medication errors and adverse events are seen frequently in surgeries. About half of all surgeries involve some kind of medication error or unintended drug side effects, Bloomberg Business reports.

The rate was calculated by researchers from the anesthesiology department who observed 277 procedures at Massachusetts General Hospital, one of America’s most prestigious academic medical centers. The rate is startlingly high compared with those in the few earlier studies. Those studies relied mostly on self-reported data from clinicians, rather than directly watching operations, and 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 today in the journal Anesthesiology.

More than one-third of the observed errors led to some kind of harm to the patient. Drugs delivered during an operation don’t have the same safeguards that other medication orders do. In most parts of a hospital, prescriptions are typically double-checked by pharmacists and nurses before they reach the patient. Operating wards are riskier.

The research may begin to draw attention to drug mistakes in the surgical suite. “It’s like a black box,” said Helen Haskell, a patient-safety advocate and founder of Mothers Against Medical Error, whose son died because of a medication error after a routine surgery. Patients under anesthesia may not be aware that an error is made, especially if there is no lasting consequence. "The rates sound high, but it’s in line with other rates of patient harm,” Haskell said. 

Not every mistake meant that the patient got the wrong drug or incorrect dose. For example, many errors had to do with properly labeling drugs when they are drawn into syringes for delivery. Because most medications just look like clear liquids, having several syringes prepared without labeling them poses a risk that the wrong one could be delivered. Those breaches in protocol were counted as errors. In about one-fifth of the problems, adverse drug reactions were considered unavoidable — for example, if a patient had a drug allergy that doctors didn’t know about ahead of time. 

The study found that some kind of error was made in about one in every 20 drug administrations. Several medications are typically used in each operation, from anesthesia to antibiotics, so that rate translated into some kind of error or adverse reaction in every other surgery. Operations that lasted more than six hours were more likely to involve an error than shorter procedures. The study suggests hospitals need to do more to improve safety. Karen Nanji, an anesthesiologist at Mass General and lead author of the study, said the solutions involve improving both processes and technology, like bar-code scanning systems that can alert doctors to potential mistakes.

One of the study’s authors disclosed a financial interest in health technology companies. The other four authors, including Nanji, disclosed no competing interests.

Source: Bloomberg Business, October 26, 2015.

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