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Study: Medication Mistakes Occur in at Least Half of Surgeries

When a patient undergoes surgery – either under emergency circumstances or in the course of a long-anticipated treatment plan – there is an expectation that the doctors, nurses and anesthesiologists involved are going to use the utmost care and caution. syringe

We all know there are many potential risks associated with surgery, but we do expect our health care providers to minimize those risks to whatever extent possible. But now, a new study published in the journal Anesthesiology reveals that medication errors are happening in about 50 percent of all surgical procedures. This figure, based on results at one prestigious hospital in Massachusetts, is significantly higher than previous estimates.

The American Association of Anesthesiologists, upon recently being presented this information, told the study authors that this significant issue is by no means unique to this location. The lead author recounted to The Washington Post that there was “not a lot of surprise” because it was widely-accepted that the self-reported numbers of medication errors during surgery were far too low. However, there was some dismay at the fact that the figure was so high, even as industry experts conceded it’s likely at least as high if not more excessive in other hospitals.

That is startling news to anyone preparing for surgery. Patients have a 50-50 chance of something going wrong. Of course, not all of those will lead to severe side effects or consequences. But researchers did find in their study that about a third of mistakes resulted in injury to the patient, including three cases in which the errors were life-threatening.

Researchers stood by and watched 277 operations between 2013 and 2014 at the Massachusetts General Hospital. What they discovered was that there was in 124 of those cases, they observing researchers identified at least one medication error, sometimes more than that in a single surgery. Of the three life-threatening mistakes, hospital staff caught the errors. In the other, it was researchers who stepped in to report a problem. In the end, no one died. That’s good news, but the point is, these were preventable errors that never should have happened in the first place. That’s called medical malpractice, and it’s when clinicians fail to adhere to the accepted standard of care.

Medications most commonly associated with mistakes included:

  • Propofol – a common sedative.
  • Fentanyl – a powerful painkiller.
  • Phenylephrine – blood pressure medication for those whose blood pressure is very low.

Part of the reason these errors occurred so frequently is that medication dispensing in the operating room happens very differently than in other settings. For example, a pharmacist or nurse in other hospital settings may have time to double or even triple-check medications prior to dispensing them to patients. But in the operating room, everything unfolds very quickly. When a patient requires a medication, it is usually given within a matter of a minute or so.

The majority of mistakes involved syringes that weren’t appropriately labeled. Often, medications are clear so it’s imperative that they be correctly labeled so clinicians can make sure they are giving patients the correct drug. The hospital where the research took place actually has a bar-code syringe labeling system. But even then, most of these errors happened when the bar code system wasn’t being used.

In any given operation about 10 medications were given during surgery. When you consider the rate of error was about 1 in every 20 medications, that’s a mistake made every other surgical procedure.

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Additional Resources:

Surgery Goes Very Wrong 50 Percent of the Time, Oct. 26,2015, by Charlotte Lytton, The Daily Beast

More Blog Entries:

Tillson v. Lane – “Loss of Chance” Doctrine in Medical Liability Cases, Oct. 30, 2015, Orlando Medical Malpractice Attorney Blog

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