A new study uncovers the most common OR error.
The first-ever study to measure medical errors in the
perioperative period (immediately before, during and after a surgical
procedure) has found that a mistake is made in every other operation. The
paper’s researchers analyzed more than 275 procedures undertaken at
Massachusetts General Hospital (MGH), uncovering that a third of the errors
resulted in patients being harmed.
The most common mistakes involved incorrect dosages being
administered, symptoms indicated by a patient’s vital signs going untreated and
mistakes in medication labeling. Of the adverse drug events that could have led
to patients being harmed, 30 percent were considered significant, 69 percent
serious and less than 2 percent were deemed to be life-threatening. Longer
procedures, particularly those lasting more than six hours, had a higher rate
of subsequent problems.
“We definitely have room for improvement in preventing
perioperative medication errors, and now that we understand the types of errors
that are being made and their frequencies, we can begin to develop targeted
strategies to prevent them,” said Karen C Nanji, the paper’s lead author.
“Given that MGH is a national leader in patient safety and had already
implemented approaches to improve safety in the operating room, perioperative
medication error rates are probably at least as high at many other hospitals.”
“Prior to our study, the literature on perioperative
medication error rates was sparse and consisted largely of self-reported data,
which we know under-represents true error rates. 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,” she added.
In carrying out the study, members of the research team
monitored anesthesia providers (anesthesiologists, nurse anesthetists, and
resident physicians) over the course of seven months, documenting any kind of
error that occurred during the process of ordering or administering a drug.
Though drug orders ordinarily go through multiple checks by different staff
members, the pace at which an operating-room patient’s condition can change
means that the required level of verification is often missed. MGH’s operating
rooms have introduced a number of electronic devices, such as barcoded syringe
labels and digital documentation in a bid to reduce the rate of mishaps, but
Nanji warns: “It’s virtually impossible to eliminate 100 percent of errors
because as the medical field advances and new medications and procedures are
introduced, these bring new opportunity for errors.
“It’s critical to continuously evaluate and identify
opportunities for improvement.”
Improving the current rate of error is paramount, as medical
malpractice lawsuits—particularly incidents that result in patients being
seriously harmed—frequently trouble the U.S. courts. Up to 19,000 lawsuits are
brought against doctors each year, with a 2006 study finding that for every one
dollar paid out in damages (and victims of medical errors are awarded an
average of $800k), 54 percent went to administrative costs such as lawyers and
representation, leading its researchers to surmise that “the overhead costs of
malpractice litigation are exorbitant.”
With the already enormous stress that hospital errors cause,
the prospect of spending hundreds of thousands of dollars on seeking justice
can only add insult to avoidable injury.
Source: thedailybeast.com
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