Study Finds Higher Rates of Perioperative Medication Errors than Previous Research

A study published in the October 2015 issue of Anesthesiology reports on the frequency of medication errors and adverse events in the perioperative setting. The rates of errors and events were significantly higher than documented by previous studies. The recent study found:

• A drug error or adverse drug event occurred in approximately 1 in 20 medication administrations and in half of the operations observed
• More than one-third of the errors caused patient harm
• About one-third of the errors resulted in an adverse drug event

Following training as observers, three anesthesiologists and one nurse anesthetist documented all medications administered, medication errors, and adverse drug events during 277 randomly selected operations. In addition to the data collected by direct observation, the study discovered medication errors and adverse drug events through chart review. The anesthesia information system was queried for errors and adverse events related to the same operations. Those cases were further reviewed for duplication; errors and events that had been missed by the observers were then recorded. The study was performed at the Massachusetts General Hospital (MGH), a large academic medical center in Boston.

The study is an important contribution to published literature about rates of perioperative medication errors. Most previous studies relied on self-reported data, which may be one reason why those rates were lower than the rates found in the study performed at MGH.

The study and a related editorial were published online (for free) to coincide with the 2015 annual meeting of the American Society of Anesthesiologists, held in San Diego in October.