Mistakes Happen in Half of Surgeries, Study Finds

Perioperative medication errors and adverse drug events occur in every second operation and in 5% of observed drug administrations, according to a study from Massachusetts General Hospital.

Perioperative medication errors and adverse drug events occur in every second operation and in 5% of observed drug administrations, according to a study from Massachusetts General Hospital (MHG).

This study is the first to measure the incidence of medication errors and adverse events during the period immediately before, during, and after a surgical procedure. The study of more than 275 operations at MGH found that one-third of errors resulted in adverse drug events or harm to patients.

“We found that just over 1 in 20 perioperative medication administrations resulted in a medication error or an adverse drug event,” lead author Karen C. Nanji, MD, MPH, of the MGH Department of Anesthesia, Critical Care & Pain Medicine, said in a statement. “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.”

A team of 4 specially trained members of the research team observed 225 anesthesia providers during 277 randomly selected operations and documented every medication administration from the time a provider took responsibility for a patient in the preoperative area until the patient arrived in the recovery room or intensive care unit.

The observers determined that 124 of the 277 operations included at least 1 medication error or adverse drug event. Of the overall 3675 medication administrations, 193 errors or adverse drug events were recorded and nearly 80% were deemed to have been preventable. Of the adverse drug events recorded, 20% were not associated with a medication error.

MGH already has an electronic anesthesia management and documentation system for medications, and the next step will be a more comprehensive decision support to reduce the incidence of errors, Dr Nanji said.

“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,” she said. “We definitely have room for improvement in preventing perioperative medication errors, 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.