Very little research exists regarding medication errors occurring in the surgical setting. Past research has generally concluded that medication errors in the operating room are exceedingly rare occurrences. This would appear counterintuitive, since one would think that medication administration errors would occur more frequently in the high stress environment of an operating room, where decisions must be made quickly, and the redundant medication administration safeguards existing in other settings do not exist.
However, recently researchers at Massachusetts General Hospital (MGH) in Boston published a study that found medication errors during surgery were much more common than previously thought. Indeed, researchers found that medication errors or unintended drug side effects occurred in approximately half—that is correct half—of all surgeries performed at MGH hospital during an eight-month period. The study titled “Evaluation of Perioperative Medication Errors and Adverse Drug Events” is published in the October 2015 journal Anesthesiology. It can be found here:
[Evaluation of Perioperative Medication Errors and Adverse Drug Events](http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2466532.)
According to the study, one-third of the medical errors identified had a negative impact on patient care, and the remainder had the potential to cause an adverse event. The study found that some kind of error was made in about one in every twenty drug administrations. Further, the study authors think that these kinds of medication errors happen with similar frequency at hospitals around the country.
Why the huge difference between the MGH study results and past research? Prior research was primarily based upon a review of medical records and physician self-reporting. In contrast, the MGH study utilized clinicians who observed the surgery for its data.
In a Bloomberg News article regarding the study, the lead researcher, Karen Nanji, M.D., explained that not every mistake meant that the patient got the wrong drug or incorrect dose. For example, many errors had to do with properly labeling drugs when they’re drawn into syringes for delivery. Because most medications just look like clear liquids, having several prepared without labeling them poses a risk that the wrong one could be delivered. Those breaches in protocol were counted as errors. In about one-fifth of the problems, adverse drug reactions were considered unavoidable—for example, if a patient had a drug allergy that doctors didn’t know about ahead of time.
“This study is especially valuable because it looked in a detailed way into medication errors in the operating room, where many of the safety strategies used in other settings have not yet been adopted, and used trained observers to document these errors,” senior author David Bates, M.D., said. “The operating room has been a hard environment to evaluate, but we used observers familiar with anesthetic care to do the observation.”
The Bloomberg News article can be found here:
[Hospitals Mess Up Medications in Surgery—a Lot](http://www.bloomberg.com/news/articles/2015-10-25/health-medication-errors-happen-in-half-of-all-surgeries)
While much has been done to reduce medication errors in other settings, it is clear that hospitals can and should be doing more in surgeries. Indeed, the study authors wrote “[t]here is a substantial potential for medication-related harm and a number of opportunities to improve safety.” Hopefully, this study will prompt hospitals to begin exploring ways to reduce these errors.
