Study: Medication errors occur in 1 out of 2 surgeries

A new study from Harvard Medical School investigating the incidence of drug dosing errors and adverse events before, during and after surgeries found a 50% rate of errors in the OR.

The study, which examined more than 275 operations at the Massachusetts General Hospital, also indicated that a 3rd of the errors discovered resulted in adverse drug events or harm to patients. The study will be published in the journal Anesthesiology.

“We found that just over one in 20 perioperative medication administrations resulted in a medication error or an adverse drug event. 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 on developing solutions to address the problems. 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,” lead author Dr. Karen Nanji of MGH’s Department of Anaesthesia said in a press release.

The study is the 1st to measure the rate of medication errors and adverse events in the perioperative period, the authors said.

In hospitals, drug orders on inpatient floors go several checks from different providers, but due to the speed of operations in ORs, double or triple checks are rarely possible, study authors said.

To conduct the study, 4 researchers observed 225 anesthesia providers during 277 randomly selected operations between November 2013 and June 2014. Observers documented every medication administration, including any kind of mistake in ordering or administering drugs, or adverse events, the study reports.

“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. 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. We already have an electronic anesthesia management and documentation system for medications, patient vital signs, and other events occurring in the operating room; and our next step will be to design more comprehensive decision support to further reduce the incidence of errors in the perioperative setting, something that I suspect the MGH will be one of the first centers to have in place,” Nanji said in prepared remarks.

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