Mistakes Occur in Half of All Surgeries

surgeriesA scary statistic came out of a new medical study – medication-related mistakes occur in half of all surgeries. This study, the first to look at adverse drug issues before, during and after surgery, was conducted at a prestigious medical center. It makes one wonder what the stats are at not-so-great hospitals.

Researchers with Massachusetts General Hospital’s anesthesiology department observed 277 surgical procedures in 2013 and 2014. The researchers found at least one medication error or adverse drug event before, during or after a surgical procedure in an astounding 124 of the surgeries the team studied. They determined that approximately 80 percent of those mistakes were preventable.

The startlingly high error rate, just published in the journal Anesthesiology, presents a significantly higher problem that shown in earlier studies, which found errors to be rare. However, those research efforts relied heavily on self-reported data from hospital staff, rather than direct observation. This study carefully watched for any incidence of medication errors and adverse drug events during the perioperative period and determined that something occurred in every second operation and in 5 percent of observed drug administrations. (The study found that an error made in about one out of 20 drug administrations, but since several take place during one surgery – such as anesthetics and antibiotics – the overall mistake rate was half of all surgeries.)

The mistakes varied in severity. There were labeling errors and documentation mistakes. There were also, however, incorrect dosages of medications given and issues with treating patient changes during surgery that indicated medication reactions. More than one-third of the errors in surgeries led to some form of harm to the patient.

“While the frequency of errors and adverse events is much higher than has previously been reported in perioperative settings, it is actually in line with rates found in inpatient wards and outpatient clinics, where error rates have been systematically measured for many years,” according to Dr. Karen Nanji, an assistant professor of anesthesia at Harvard Medical School in Boston and the study author. She noted in a press statement about the study showing that mistakes occur in half of all surgeries, there is definitely room for improvement to prevent perioperative medication mistakes, and “now that we understand the types of errors that are being made and their frequencies, we can begin to develop targeted strategies to prevent them.”

The study is just the latest focusing attention on medical errors and the need to reduce them since 1999. That was when they were first identified as a leading cause of death in the U.S., killing approximately 44,000 people annually, which is a higher rate than auto accidents. Since that time, medical professional have worked to improve safety using simple tools like checklists before, during and after a procedure or more sophisticated ones like electronic systems for prescribing and warning doctors about potential medication errors.

Drugs delivered during an operation, however, do not always have the same scrutiny and safeguards other hospital medication orders do. In other parts of a hospital, pharmacists and nurses check inpatient prescriptions multiple times these days before they reach patients. However, “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,” Nanji acknowledged.

The researchers were quick to point out that no patient died because of medication mistakes during the operations and only three of the error were potentially life-threatening. However, the study showing that half of all surgeries have some type of medical mistake indicates that hospitals need to do more to improve safety.

Written and edited by Dyanne Weiss

Sources:
Massachusetts General Hospital: Mass. General study finds medication error or adverse event associated with 5 percent of perioperative drug administrations
Bloomberg: Hospitals Mess Up Medications in Surgery—a Lot
Boston Globe: Drug errors are common in surgery, MGH-led study says

U.S. Navy Photo by Chief Mass Communication Specialist Michael Ard

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