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Medical Care

Medication Errors & Adverse Drug Events in 1 out of 2 Surgeries

The first study to measure the incidence of medication errors and adverse drug events during the perioperative period – immediately before, during and right after a surgical procedure – has found that some sort of mistake or adverse event occurred in every second operation and in 5 percent of observed drug administrations. The study of more than 275 operations at Massachusetts General Hospital, which was published October 25th 2015 inAnesthesiology, the official medical journal of the American Society of Anesthesiologists, also found that a third of the errors resulted in adverse drug events or harm to patients. The report was published online to coincide with a presentation at the ANESTHESIOLOGY 2015 annual meeting in San Diego.

A release from Mass. General quotes lead author Karen C. Nanji, MD, MPH, of the MGH Department of Anesthesia, Critical Care & Pain Medicine, as saying,  “We found that just over 1 in 20 perioperative medication administrations resulted in a medication error or an adverse drug event. Given that Mass. General is a national leader in patient safety and had already implemented approaches to improve safety in the operating room, perioperative medication error rates are probably at least as high at many other hospitals. Prior to our study, the literature on perioperative medication error rates was sparse and consisted largely of self-reported data, which we know under-represents true error rates. Now that we have a better idea of the actual rate and causes of the most common errors, we can focus in developing solutions to address the problems.”

Nanji explains that, while drug orders on inpatient floors go through a process in which they are checked several times by different providers – the ordering physician, pharmacist and nurses administering the medications – the rapidity with which the condition of patients in the operating room can change doesn’t allow time for that sort of double- and triple-checking during surgical procedures. Although operating rooms at MGH and other hospitals have installed electronic documentation and bar-coded syringe labeling systems to reduce errors, in other patient care the measures that have cut errors areas have all started with a rigorous analysis of the incidence and type of errors that were occurring.


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