Medication Errors and Adverse Events Found In Many Surgeries at MassGeneral



“Whoops!” is definitely the last thing you would want to hear from a medical professional after having surgery. Mass General is Harvard’s oldest and largest teaching and research hospital. It conducted a study that found a worrying number of medication errors during and after surgeries performed at the hospital. They defined a “medication error,” as any mistake in the process of ordering and administering a drug. The study also looked at adverse reactions to medications. They found occurrences of error or adverse reaction in roughly half of the surgeries that they analyzed.

Here are some of the findings:

  • Nearly half (124 out of 277) of the observed operations included at least one medication error or adverse drug event.
  • Of the almost 3,675 medication administrations in the observed operations, 193 adverse events were recorded, including 153 medication errors and 91 adverse drug events. Nearly 80 percent of those events were determined to have been preventable.
  • Medication errors and adverse drug events were more likely to occur during longer procedures, particularly those lasting more than six hours and involving 13 or more medication administrations.

The study is a sobering look at the administration of drug treatments in surgical procedures and recovery. The numbers would be discouraging for any public hospital, but the fact that it was happening in one of the most prestigious in the world eliminates any dismissal of the evidence as a fluke or local aberration. Mass General is a leader in many areas and in this case they pulled the mirror up and took a hard look and realized they have some work to do. So how did these errors happen and what can be done?

The most frequent errors involved mistakes in labeling, dosage, and failure in diagnosis and administration. The medical operation usually begins with meetings with an anesthesiologist to determine the proper amount and type of anesthetic required for the surgery. It is important to be honest here. Personal history of drug and alcohol use should be accurate and given up freely. In one of the most agile performances in the annals of anesthesiology, during a hip surgery, Hunter S. Thompson’s chart read “500cc of whiskey every two hours or as needed.” Ultimately they induced a coma because the alcohol withdrawal he suffered during the operation threatened his life. He survived.

After a surgery is completed any number of treatments may be required to aid recovery. Pain management is ubiquitous, as well as treatments to prevent infection and others specific to the type of operation. Here is where there are many possible problems. An administrative problem could produce an error regarding dosage, and a lack of oversight could cause a failure to anticipate a negative drug interaction. As a patient it is important to be an active participant, not only with personal history, but using common sense if you sense there may be an issue. A self-reflective study like the one conducted at Mass General is the first step in looking at common practices and diagnosing improvements. It is a frightening number of errors, but it highlights that our healthcare system is ultimately a very human endeavor.

See how RxREVU is developing better prescribing tools at the point of care to help reduce medication errors and adverse drug events at www.rxrevu.com.