A new study found that surgery goes very wrong in every other operation.
The study of more than 275 procedures performed at Massachusetts General Hospital (MGH) was the first to examine medical mistakes in the perioperative period, which includes the time before and after the surgery, as well as during the procedure. The study found mistakes in 50 percent of cases, a third of which caused harm to patients.
The errors that occurred most frequently were administering the incorrect dose of a medication, failing to treat symptoms that showed up in a patient’s vital signs and errors in labeling medications. Of the adverse drug events with the potential to cause harm to patients, 69 percent were deemed serious, 30 percent were significant, and below 2 percent were considered life-threatening. The rate of problems after surgery increased with longer procedures, especially if they lasted over six hours.
Karen C. Nanji, the lead author of the study, said that perioperative error rates involving medication may be even higher at other hospitals, because MGH had already initiated programs to improve safety in surgeries, and in fact is considered a patient safety leader.
To conduct the study, researchers monitored those providing anesthesia, including anesthesiologists, resident physicians and nurse anesthetists, over seven months, documenting all errors involving ordering or administering medications. Safety procedures such as digital documentation, barcoded syringe labels and multiple checks by different staff members, were not fully effective, the study found.
Improving patient safety is an important national health issue. Although up to 19,000 medical malpractice lawsuits are filed each year, only a fraction of patients who are harmed are able to obtain justice through the legal system, and money cannot make up for the harm suffered by many patients.
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