A study just released in the journal Anesthesiology that looked at medication errors made during surgery found that there were medication errors in nearly half of the 277 operations observed, the Washington Post reported Oct. 28. The rate of errors was found to be higher than previously known in studies of self-reported errors. Surgeries in this study were observed by three anesthesiologists and one nurse anesthetist, all of whom were active and practicing in their field.
The study took place over an eight month period at Massachusetts General Hospital in Boston. The annual U.S. News and World Report ranking of best hospitals in America ranked Mass General as number one in the country on Jul. 21. In 2014, the hospital was ranked number two.
The study is titled “Evaluation of Perioperative Medication Errors and Adverse Drug Events.” The four observers were present for 277 randomly selected surgeries over an eight month period from November 2013 to June 2014. The observers witnessed 3,671 administrations of medication and documented 193 medication errors or adverse events. Excluding 40 errors that were deemed non-preventable, the 153 preventable events included 99 that were termed serious, 53 were significant and three were life threatening.
Of the 70 medication errors observed with a potential adverse drug event, just four were intercepted. Some 51 of the medication errors actually led to an adverse drug event. Nearly half, 24, involved inappropriate medication doses while just under one third, 16 events, involved an omission of a medication or failure to act.
The study data is complex since, in some cases, there was more than one error or event. Neither the type of anesthesia, general vs. sedation, nor the type of provider, M.D vs. nurse or staff. produced a statistical difference in error rate. An increase in errors was seen in surgeries that used 13 or more medications or that lasted longer than six hours.
Mass General quotes the lead author, Karen C. Nanji, M.D., M.P.H., as stating:
We definitely have room for improvement in preventing perioperative medication errors
The study does suggest some changes in the surgical process that could reduce medication errors and adverse drug reactions. For example, 35 of the 153 errors involved giving an incorrect dose of medication and nine more involved giving the incorrect medication.
Use of standard bar code medication labeling, computerized medication dose calculation and automated reminders for the timing of additional doses of medication would markedly reduce these errors. In addition, systems that permit documentation of medications and processes need to be available before and during surgery and not just upon completion.