Hospitals

Mass General study shows shockingly high surgical medication error rates

The case against the quality of American healthcare just gets stronger, and patients continue to suffer.

The case against the quality of American healthcare just gets stronger, and patients continue to suffer.

Barely a month after the Institute of Medicine dropped a bombshell about the scope of diagnostic error in this country comes news that nearly half of all surgeries observed for a study involved at least one medication error or adverse drug event. About 5 percent of medication administrations produced an error or adverse event, and one-third of the errors actually harmed patients.

What’s notable about this story is that it comes from a major academic medical center that’s routinely named among America’s best hospitals — perhaps on reputation more than hard data — and that it’s based on actual observation, not self-reports from clinicians.

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A paper presented over the weekend at the American Society of Anesthesiologists’ annual meeting and published online in the journal Anesthesiology found these high error rates at the prestigious Massachusetts General Hospital in Boston.

Lead author Dr. Karen C. Nanji, a Mass General anesthesiologist, said that mistakes can happen more often in surgical suites than in standard inpatient rooms because the fast pace of patient condition changes during surgery does not always allow for multiple medication checks prior to administration. “Now that we have a better idea of the actual rate and causes of the most common errors, we can focus in developing solutions to address the problems,” Nanji said in a Mass General press release.

“Patients don’t need to go into surgery thinking that they’re going to have lasting permanent harm every second operation,” Nanji added in an interview with Bloomberg.

“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,” said senior study author Dr. David Bates of the affiliated Brigham and Women’s Hospital.

Photo: Rodale.com