Even at a prestigious academic medical center like Massachusetts General Hospital in Boston, medication errors and adverse drug events prove problematic. Recent research from MGH found some medication mistake or adverse event occurred in every other operation studied.
The MGH study is the first to measure the incidence of medication errors and adverse drug events during the perioperative period. Researchers observed 225 anesthesia providers — including anesthesiologists, nurse anesthetists and resident physicians — during 277 operations conducted at the hospital from November 2013 through June 2014.
The researchers defined medication errors as any kind of mistake in the process of ordering or administering a drug. They defined adverse drug event as harm or injury to a patient related to a drug, whether or not it was caused by an error.
They found:
1. Nearly half (124 out of 277) of the observed operations included at least one medication error or adverse drug event.
2. Of the almost 3,675 medication administrations in the observed operations, 193 adverse events were recorded, including 153 medication errors and 91 adverse drug events. Nearly 80 percent of those events were determined to have been preventable.
3. One-third of the observed medication errors led to an adverse drug event, and the remainder had the potential to cause an adverse event. Of the adverse drug events that were recorded, 20 percent were not associated with a medication error.
4. Mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patient's vital signs and documentation errors were the most frequently observed errors.
5. Of all the observed adverse drug events and the medication errors that could have resulted in patient harm, 30 percent were considered significant, 69 percent serious and less than 2 percent life-threatening; none were fatal. Operating room staff intercepted four adverse drug events or medication errors before they affected the patient.
6. In addition to errors that occurred during and right after surgical procedures, the researchers observed some sort of mistake or adverse event in 5 percent of observed drug administrations.
7. Medication errors and adverse drug events were more likely to occur during longer procedures, particularly those lasting more than six hours and involving 13 or more medication administrations.
"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," said lead author of the study Karen Nanji, MD. "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."
More articles on errors and adverse events:
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How to eliminate 'never events': 5 takeaways about EHR design, use error and patient harm
5 ways measuring the diagnostic process can reduce errors