Sunday, March 11, 2007

Medication Errors During Surgeries Particularly Dangerous

Medication Errors During Surgeries Particularly Dangerous

By Amanda Gardner, HealthDay Reporter
Washington Post, Tuesday, March 6, 2007

Medication errors that occur during the course of a surgical procedure are three times more likely to harm a patient than errors committed during other types of hospital care, a new report shows.

Some 5 percent of such errors resulted in harm, said Diane Cousins, vice president of the department of Healthcare Quality and Information at the United States Pharmacopeia (USP), which conducted the survey. The nonprofit group sets safety standards for pharmaceutical care that are used worldwide.

The report analyzed 11,000 errors reported by 500 hospitals between 1998 and 2005. This is the largest known analysis of medical errors related to surgery, according to the USP.

Overall, there were about 500 harmful errors, including four fatalities, one of which involved a child.

Errors were most common in the operating room and were most likely to affect children. Almost 13 percent of pediatric errors resulted in harm, proportionately higher than any other group studied.

The most common medication errors in the surgery setting were receiving the wrong drug, the wrong amount of a drug, receiving the drug at the wrong time or not receiving the drug at all. Antibiotics and painkillers were most frequently found to be involved in errors.

The report focused on four parts of the "surgical continuum" -- outpatient surgery, the preoperative holding area, the operating room, and the post-anesthesia care unit.

There were 2,437 reported errors in outpatient surgery, 3.3 percent of them resulting in harm. In the pediatric population, 3.6 percent of errors resulted in harm, vs. 5.1 percent in adults and 5.1 percent in geriatric patients. Problems most commonly involved central nervous system medications and antimicrobials, with central nervous system drugs most likely to result in harm.

In the preoperative holding area, there were 779 errors, with 2.8 percent resulting in harm. For children, 4.2 percent of errors resulted in harm, compared to 7.1 percent for adults and 2.6 percent for elderly patients.

In the operating room, 3,773 errors were reported, 7.3 percent of which resulted in harm. Almost 17 percent of errors resulted in harm in children, 11.3 percent in adults and 10 percent in geriatric patients. Two of the errors caused or contributed to patient deaths.

Finally, in the post-anesthesia care unit, 3,260 errors occurred, of which 5.8 percent resulted in harm. Here, more than 20 percent of errors in children resulted in harm, compared with 8.7 percent in adults and 8.8 percent in elderly patients. Morphine drips and other patient-controlled analgesia machines were often involved in the most harmful errors. Tubing misconnections were also involved, as was an absence of reliable allergy information. Medication errors caused or contributed to two deaths.

Overall, Cousins said, the so-called "surgical continuum" was really a fragmented system in which numerous hand-offs of patients resulted in lack of coordination and errors.

The report included 47 recommendations, more than any other year. These included implementing strategies to improve communication among team members, designating a pharmacist to coordinate medication safety on behalf of a patient, working to ensure that medications are administered on time (particularly antibiotics) and issuing a call to manufacturers to provide ready-to-use sterile packaging, especially for drugs administered to children.

More information
Find out more about the report at USP.

SOURCES: March 6, 2007, teleconference with Diane D. Cousins, R.Ph., vice president, Department of Healthcare Quality and Information, USP;MEDMARX Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

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Medication Errors Are Studied

Medication Errors Are Studied

Medication Errors Are Studied
By DONALD G. McNEIL Jr., New York Times, March 7, 2007

Young children are the most likely victims of surgery-related medication mistakes, a new study has found, and poor communication as the patient moves from the operating room to recovery is the most likely culprit.

The study, released yesterday, was done by the United States Pharmacopeia, which sets standards for the pharmaceutical industry, and by the Uniformed Services University of the Health Sciences in Bethesda, Md., and two nurses’ associations.

Medical error has been a charged topic ever since a 1999 report by the Institute of Medicine, “To Err Is Human,” estimated that such mistakes led to as many as 98,000 deaths a year — more than highway accidents and breast cancer combined.

The current study did not try to estimate total error rates. Instead, it analyzed 11,000 mistakes that had been voluntarily and anonymously reported to the pharmacopeia by hundreds of hospitals since 1998.

The study was confined to errors made on patients undergoing surgery, and the rate of harm, 5 percent, was much higher than is typical for medication errors. Among children it was 12 percent.

Most of the errors involved painkillers and antibiotics. Four resulted in deaths, and one death was of a child.

Problems typically arose when a patient was handed off from the preoperative team to the operating room to the recovery room to the regular ward nurses, said Diane Cousins, a health care specialist at the pharmacopeia and one of the authors. “The system is often very fragmented,” Ms. Cousins said.

Typical dangerous mistakes were failures to administer antibiotics before surgery, failures to note allergies, errors in setting pumps that dispense blood thinners or painkillers, and giving overdoses to infants.

In several cases described in the report, poor penmanship, careless listening or bad arithmetic caused patients to get doses 10 or even 50 times as high as they should.

“It’s beyond troubling that the smallest, youngest patients are the ones most at risk,” Ms. Cousins said.

There are 10,000 drugs in the marketplace, she said, and many have never been tested on children in clinical trials, so doses are often made by guesswork based on weight, involving conversion of pounds to kilograms, sometimes by nurses who are not pediatric specialists.

“These may be back-of-the-envelope calculations not checked by anyone,” she said, “and they are often in very tiny amounts — milliliters — and that in itself breeds errors.”

The report made 42 recommendations, among them that hospitals improve communication and designate a pharmacist to be consulted for each patient.

Since 1999, committees investigating medical mistakes have routinely recommended that hospitals install computerized systems for prescribing drugs, which can sound alarms when a toxic combination is ordered for a patient. But fewer than 10 percent of all hospitals have them.

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