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Medication errors seen in half of all operations

Staff writer |
In a new study on how often medication errors occur during surgery, researchers report that mistakes were made during almost half of the operations they analyzed.

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The mistakes included drug labeling errors, incorrect dosing, drug documentation mistakes, and/or failing to properly treat changes in a patient's vital signs during surgery.

Overall, a medication error or adverse drug event was documented in 124 of 277 surgeries. Of the 3,675 medication administrations (most patients receive more than one drug during surgery), 193 medication errors and adverse drug events were recorded, the Harvard researchers said. And almost 80 percent of those events were determined to have been preventable.

The findings stem from the in-house efforts of Boston-based Massachusetts General Hospital to quantify and address drug-error risk during surgery.

"This is the first large-scale look at medication errors in the time immediately before, during and directly after surgery," said study author Dr. Karen Nanji, an assistant professor of anesthesia at Harvard Medical School in Boston. "But in my opinion, while there is much room for improvement, our results are not surprising," she added.

"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 suggested.


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