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About half of all surgeries involve some kind of medication error or unintended drug side effects, if a new study done at one of America’s most prestigious academic medical centers is any indication.
The rate, calculated by researchers from the anesthesiology department at Massachusetts General Hospital who observed 277 procedures there, is startlingly high compared with those in the few earlier studies. Those earlier studies relied mostly on self-reported data from clinicians, rather than directly watching operations, and found errors to be exceedingly rare.
“There is a substantial potential for medication-related harm and a number of opportunities to improve safety,” according to the new study, published today in the journal Anesthesiology . More than one-third of the observed errors led to some kind of harm to the patient.
[Also Covered By]: http://www.fiercehealthcare.com/story/medication-errors-occur-half-surgeries-mgh-study-finds/2015-10-26
(Score: 4, Insightful) by bradley13 on Tuesday October 27 2015, @07:34PM
Interesting study. Note that the study is quite harsh in what it counts as errors. It included unexpected allergic reactions to drugs, i.e., no one knew the patient had the allergy. Kind of hard to prevent.
It also includes cases where drug doses are prepared during the surgery; drugs that may look the same in the syringe. In this case, they are supposed to be labelled to prevent a mix-up. If they were not labelled, this was counted as an error, even if the personnel did not mix up the drugs.
All valid criticisms, but not really "messed up medications", as the headline implies.
Everyone is somebody else's weirdo.
(Score: 2) by VLM on Tuesday October 27 2015, @08:28PM
I looked at the breakdown too.
Looks like about 80% were either BS or unavoidable lightning strikes. That means things will be "fixed" by having better labeling, or armed guards hovering over morphine syringes. Not really helpful. About 20% were wrong dosages and that sounds like something technology could fix, somehow, but the 80% being a bigger part of the metric we'll end up with just as many patients getting the wrong dose although via extensive training the morphine will be properly locked up in a safe and labels will have written names not initials of the nurse and other paperwork BS.
Because of how the results are reported, the likely outcome will be worse patient care not better.
(Score: 3, Interesting) by physicsmajor on Tuesday October 27 2015, @09:36PM
The more important, but non-obvious, reason this article was published from the anesthesia perspective is interesting. On a meta level, why would Harvard be publishing data that amounts to "anesthesiologists are terrible" - and not just any anesthesiologists, their department?! To understand this we need a little more background.
See, anesthesiologists have a great gig. Limited hours, excellent pay. There's one big, looming problem though - the safety measures and monitoring used during these procedures are more than smart enough to do the vast majority of what constitutes their jobs. It's really a control system problem, and memorization-focused people coming through medical schools by and large aren't the best to be at the wheel. The best anesthesiologists are the rare few engineers who manage to survive the abuse of medical training, who keep everything fully green. But this isn't required. You can get by as an anesthesiologist basically sitting back until the machines alarm, then fix things. The monitors are that good.
The obvious next question is: if the monitors are that good, can't we program in the appropriate action to be taken automatically? Such a system can definitely provide better control than humans can. It's a relatively simple 1-D DSP/control theory problem. And people are looking into this. Recently at least one company has come out with a fully automated solution. A machine which can do everything except hook the patient up. These are only approved in Europe for conscious sedation (e.g., colonoscopy) at this point, but it's coming fast.
This terrifies the anesthesiologists.
Circling back around, this type of article is getting published expressly because they're trying to build a trove of citations for a specific purpose. They need a list of citations noting all the nasty and unpredictable things which happen. That is the only reason Harvard is publishing an article which, on its face, seems like it makes them look bad. I don't know which side is going to win, but it'll be interesting to watch it play out.
(Score: 0) by Anonymous Coward on Tuesday October 27 2015, @11:01PM
I'd be more willing to believe this if it came from MedicineMajor rather than Phisicsmajor.
(Score: 2) by physicsmajor on Tuesday October 27 2015, @11:51PM
Perhaps one can be both?
(Score: 2) by frojack on Tuesday October 27 2015, @11:17PM
I haven't dug through all the inter-twined associations, but a cursory glance at the paper suggests very little about Harvard, other than the hospital is a teaching hospital for Harvard.
The University probably exercises little in the way of control over papers published by hospital people.
The money came from Doctors Company Foundation, the nation’s largest insurer of medical professional liability for physicians, surgeons, and other health professionals. Sounds like they would have an interest in this subject.
If anything, Harvard was along for the ride, and never got even direct reference.
I don't believe Harvard IS involved in publishing this at all.
Its far more likely Insurance Companies are looking to enforce standards and cut mal-practice payments.
This work was supported by grants from the Doctors
Company Foundation (Napa, California) and the National
Institute of General Medical Sciences (Bethesda, Maryland)
of the National Institutes of Health (Award Number
T32GM007592). The content is solely the responsibility of
the authors and does not necessarily represent the official
views of the Doctors Company Foundation or the National
Institutes of Health. Neither the Doctors Company Foundation
nor the National Institutes of Health had any role in the
design and conduct of the study; collection, management,
analysis, and interpretation of the data; or preparation,
review, or approval of the manuscript.
No, you are mistaken. I've always had this sig.
(Score: 2) by VLM on Wednesday October 28 2015, @11:30AM
This terrifies the anesthesiologists.
I suspect its a nearly perfect analogy for replacing pharmacists with vending machines.
As long as the system can afford to remain corrupt, we'll have extremely highly paid human vending machines and human PID controllers. After that, well...
Personally I expect their elimination to being in the military. If a mobile surgical hospital can replace two expensive officers and their part of the logistics tail with a PID controller running on an iphone and a vending machine, they'll do it.
Another thing to watch for is outsourcing just like radiology. One dude in India will "supervise" 16 anesthesia machines over the internet.
(Score: 3, Interesting) by frojack on Tuesday October 27 2015, @10:18PM
If they were not labelled, this was counted as an error, even if the personnel did not mix up the drugs.
Drugs Prepared during surgery includes those drugs drawn from the Manufacturers package (vial) into an unlabeled syringe, and then immediately administered, often by the same person. This category alone amounted to 24% of the errors. If this happens IN the operating room its still classed as an error. See the Anesthesiology journal linked PDF Page 8. See also the limitations of their study column 2 page 8.
Apparently, the recommended practice is to label the syringe before or immediately after you fill it. Furthermore, they want all those syringes BAR-CODED. And of course, they want those barcodes scanned before administration. Scanning the source is not sufficient because it doesn't record dosage (It hold more than a syringe could).
Having had a surgery earlier this summer, I can't speak to the Operating Room procedures (thankfully), but every single drug administration pre-op and post-op was preceded by the standardized dance: Scan nurse/doctors badge, scan my wrist band, scan the drug packaging or syringe, then administer. Then lots of computer terminal typing.
I asked if that was for billing purposes, and the nurse said yes, but more importantly it was for for computerized drug checking, drug interaction checking, prescription matching, recording, etc. She said the computer terminal would Alarm immediately and loudly both in the room and at the desk if she scanned the wrong drug, wrong amount, etc. after scanning my band.
She said the desk would "send the F16s" if that ever happened.
(And she was quick to point out that had never happened and would never happen on HER watch - and I believed her).
No, you are mistaken. I've always had this sig.