Study: Medication Errors In Half Of All Surgeries

By Christine Kern, contributing writer

Medication errors or adverse drug events represent a serious issue in surgical care according to a study conducted at Massachusetts General Hospital, The study discovered a medication error or adverse drug event in 124 out of 277 surgery operations conducted over a seven-month period between 2013 and 2014, roughly 50 percent of all surgeries.

The study, Evaluation of Perioperative Medication Errors and Adverse Drug Events, found there were 193 medication errors or adverse events out of 3,675 medication administrations, of which nearly 80 percent were preventable, 64.7 percent were serious and 2 percent were life-threatening. The study identified medication mistakes as drug labeling errors, incorrect dosing, drug documentation errors, and/or failing to properly treat changes in a patient’s vital signs during surgery. 

“These rates are markedly higher than those reported by retrospective surveys. Specific solutions exist that have the potential to decrease the incidence of perioperative medication errors,” said Dr. Karen Nanji, study lead author and assistant professor of anesthesia at Harvard Medical School.

The Institute of Medicine first reported on medical error deaths in 1999, kicking off off a large-scale healthcare focus on error reduction. However, as previously reported in Healthcare Dive, a 2013 independent study has shown no progress on reducing errors and over 200,000 people die every year from preventable medical mistakes.

An editorial published in the same issue as the medication errors study suggests the results should “stimulate discussion and prompt improvements in medication safety in the operating room.” As greater emphasis is being placed on patient outcomes and improvement patient experiences and safety, this study demonstrates a place where work still needs to be done to create more positive results.

The editorial concludes, “Their results have confirmed a problem that anesthesiologists have suspected for years. We must now promote change by doing what anesthesiologists do best: breaking down a tough problem into manageable pieces and then building a safer system for patients undergoing anesthesia.”