Medication errors occur in half of surgeries, MGH study finds

By Aine Cryts

Medication errors or unintended drug side effects occurred in about half of all surgeries done at Boston's Massachusetts General Hospital (MGH) within an eight-month period, according to a study conducted at the world-renowned healthcare organization.

While the research was conducted on procedures that took place at MGH, it indicates that similar failures happen at hospitals around the country.

The study found that some sort of mistake or adverse event occurred in every second operation and in 5 percent of observed drug administrations, according to a study announcement

In addition, one-third of the medical errors identified in the MGH study had a negative impact on patient care, while the remainder had the potential to cause an adverse event, concluded researchers in the hospital's anesthesiology department who observed 277 procedures there. Previous studies, in contrast, have found these types of errors to be incredibly rare.

"There is a substantial potential for medication-related harm and a number of opportunities to improve safety," study authors wrote in the journal Anesthesiology.

Although hospital safety came to the forefront in 1999 with the Institute of Medicine's landmark report, "To Err is Human: Building a Safer Health System," it's an effort that continues throughout the healthcare industry. Current safety-improvement efforts largely surround processes and technology, such as bar code syringe-labeling systems to prevent drug-administration errors, Karen Nanji, M.D., an anesthesiologist at MGH and a lead author of the study, told Bloomberg Business.

Indeed, the most frequently observed errors in the MGH study, according to an announcement, included the following:

  • Mistakes in labeling
  • Incorrect dosage
  • Failure to treat a problem indicated by a patient's vital signs
  • Documentation errors

"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," added study senior author David Bates, M.D., of the Department of Medicine at Brigham and Women's Hospital. "The operating room has been a hard environment to evaluate, but we used observers familiar with anesthetic care to do the observation."

To learn more:
- see the abstract
- here's the article from Bloomberg Business
- read the MGH study announcement

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