Researchers from the Massachusetts General Hospital directly observed a number of surgeries and found that half of these operations involve unwanted side effects from certain drugs and medication errors.
The study assessed approximately 277 surgical procedures during the perioperative period or before, during and after the surgery performed within the MGH.
Previous studies showed that there were little to no known errors during surgeries, but these studies were self-reported data and were not as accurate as direct observation. Researchers said that the current study will contribute to the development of solutions to address the problems.
In a report which will be issued in the journal Anesthesiology, researchers found that mistakes occurred in five percent of drug administrations and one in every 20 drug administrations have caused adverse effects to patients.
Dr. Karen Nanji, lead researcher from the hospital's Department of Anesthesia, Critical Care, and Pain Medicine, explained that error rates might even be higher in other hospitals as MGH had already applied methods to improve patient safety.
Nanji described the process of checking the drugs. The pharmacist, ordering physician, and the nurse administering the medications all check the drugs and sometimes, time prevents their capability to double-check or triple-check the medication.
"In the operating room, things happen very rapidly, and patients' conditions change quickly, so we don't have time to go through that whole process, which can take hours," Nanji said.
Nanji said that the errors committed in the errors may lead to adverse effects but none have ever led to death. When a patient experiences a change in vital signs or an increased risk for infection, the harm would also elevate.
Four trained members of the MGH research team observed 225 resident physicians, nurse anesthetists and anesthesiologists during 277 surgical procedures conducted from Nov. 2013 to June 2014, all of which were randomly-selected. For this study, "errors" were distinguished as any mistake committed during drug administration and any injury or harm related to a drug which was given to a patient and not necessarily committed as an error.
Researchers discovered that the most common type of mistakes committed were errors in labeling, overlooking to treat a problem related to the vital signs of a patient, errors in documentation and incorrect dosage.
Nanji added that because of the findings, they definitely can improve their methods in preventing perioperative medication errors, and that they can develop strategies to prevent these errors and their frequencies.
Photo: Army Medicine | Flickr
