Mistakes? Yes, mistakes. A team of researchers observed nearly 3,675
medication administrations made during 277 surgeries. The results were
eye opening: 124 of the cases involved at least 1 medication error (a mis-
take in ordering or administering a drug) or adverse drug event (harm or
injury related to a drug, regardless of whether it was caused by an error).
Of the 193 medication-related errors or adverse events they observed,
nearly 80% were preventable.
One in 20 administrations — or 1 during every other operation —
resulted in a medication error. One-third of the errors led to some
kind of patient harm, ranging from skin rashes to changes in blood
pressure or increased infection risk, and the remainder had the poten-
tial to cause harm.
The most common errors that led to patient harm involved wrong
doses, omitted medications and failing to intervene when necessary,
based on changes in the patient's condition. Karen Nanji, MD, MPH, an
anesthesiologist at Massachusetts General Hospital in Boston, Mass., and
her colleagues have implemented interventions designed to eliminate
the types of errors they found. Can their practice improvements pro-
mote medication safety in your facility?
1. Barcode-assisted syringe labeling. This technology was in
place in most of Mass General's ORs during the study period, but 24%
of the errors involved labeling mistakes when the technology wasn't
installed or providers used workarounds to circumvent its use.
If you're using barcode-assisted labeling, place the technology at the
immediate point of care and make sure it's user-friendly and performs
fast enough to keep up with the pace of surgery, says Dr. Nanji. She
also recommends that you trial any platform you're thinking of imple-
menting to make sure it's compatible with the complexity of deliver-
ing medications in the OR. Also train your staff extensively on new
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SURGICAL
ERRORS
