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High rates of medication errors, adverse drug events found in operations

A prospective study of perioperative medication administration found significant medication errors and adverse drug events, according to research published in Anesthesiology.

Karen C. Nanji, MD, MPH, department of anesthesia, critical care and pain medicine at Massachusetts General Hospital, and colleagues reported that more than one third of the errors led to observed patient harm.

To assess medication errors and adverse drug events, trained staff observed operations over an 8-month period, from November 2013 to June 2014. Medication errors and adverse drug events were identified by observation and retrospective chart reviews. All events were reviewed by independent experts. A committee also graded adverse drug event severity and preventability on four-point Likert scales.

Nanji and colleagues reported that the study population consisted of 74 attending anesthesiologists, 51 certified registered nurse anesthetists and 101 staff. Data collection resulted in 105 observation days, 277 operations and 3,671 medication administrations.

Results showed that 124 operations (44.8%) included one or more medication error and/or adverse drug event. The researchers identified 211 medication errors and/or adverse drug events: 172 (81.5%) were directly-observed and 39 (18.5%) were found in chart reviews.

The committee excluded 14 (6.6%) of the errors and four had no potential for harm. The final sample included 193 events (5.3%; 95% CI, 4.5-6).

Of the 193 events, 153 (79.3%) were medication errors and 91 (47.2%) were adverse drugs. Nanji and colleagues wrote that 153 events (79.3%) were judged to be preventable, while 40 (20.7%) were considered nonpreventable. Additionally, none of the events were fatal, three (1.6% were life-threatening, 133 (68.9%) were serious and 57 (29.5%) were significant.

Researchers found that errors most commonly resulted from labeling error (24.2%), wrong dose (22.9%), omitted medication/failure to act (17.6%) and documentation error (17%).

"We found that approximately one in 20 perioperative medication administrations, and every second operation, resulted in an [medication error] and/or an [adverse drug event]," Nanji and colleagues wrote. "More than one third of these errors led to observed patient harm, and the remaining two thirds had the potential for patient harm. These rates are markedly higher than those reported by existing retrospective surveys. Future analyses should target the creation and the implementation of process- and technology-based solutions that may address the root causes of the errors to reduce their incidence." – by Chelsea Frajerman Pardes

Disclosures: One researcher on Patent No. 6029138 held by Brigham and Women's Hospital on the use of decision support software for radiology medical management, licensed to the Medicalis Corporation. They hold a minority equity position in the privately held company Medicalis. They serve on the board of SEA Medical, which makes technologies that can identify medications in solution. They receive equity and cash compensation from QPID, Inc., a company focused on intelligence systems for electronic health records. Please see the full study for a list of all other authors' relevant financial disclosures.