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Half of All Surgeries May Involve an Error in Medication

half of all surgeries may involve medication error50/50 may seem like pretty good odds. If there was a 50% chance of sunshine, you might still keep those outdoor plans on a Saturday. An investment with a 50% chance of a big payoff is a chance you might be willing to take.

The view becomes a little less optimistic, however, when a study suggests that 1 in every 2 surgeries occurs with some sort of medication error.

In a review conducted by Massachusetts General Hospital of 277 of its own surgeries, 124 of them occurred with some sort of medication error or other type of “adverse drug event.” The errors included “drug labeling errors, incorrect dosing, drug documentation mistakes, and/or failing to properly treat changes in a patient’s vital signs during surgery.”

Dr. Karen Nanji, the author of the study and an assistant professor of anesthesia at Harvard Medical School, says that “this is the first large-scale look at medication errors in the time immediately before, during, and directly after surgery.” She is not surprised by the results.

“In fact, it’s very likely that this issue is even more problematic given that Mass General is a national leader in patient safety, and has gone out of its way to study this issue in order to improve outcomes,” she says.

The study suggests that much of the blame for the errors lies with the surgical environment itself. While patient care is closely monitored in hospital rooms and can, in many cases, follow a predictable schedule, surgery can be full of events happening in rapid succession. Surgeons must make frequent, immediate decisions with little time to consider alternatives.

Two-thirds of the errors found in the study were classified as “serious” and two percent were “life-threatening,” although the report states that no one died as a result of an error. Most impactful, however, is the fact that 80% of the errors were found to have been avoidable.

“And yet, as the saying goes, to err is human,” says Dr. David Katz. Dr. Katz has a particular interest in medication and other errors as the director of the Yale University Prevention Research Center. “So, errors will occur if human behavior is the only safeguard against it.”

What’s the solution? According to Dr. Katz, “human behavior cannot be the only safeguard against error.” He believes that a “multi-layered defense, involving careful humans backing one another up, and automatic systems backing up the humans” is the path toward the prevention of future medical errors.