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posted by martyb on Tuesday October 27 2015, @07:27PM   Printer-friendly
from the added-surgical-risk dept.

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.

http://www.bloomberg.com/news/articles/2015-10-25/health-medication-errors-happen-in-half-of-all-surgeries

[Also Covered By]: http://www.fiercehealthcare.com/story/medication-errors-occur-half-surgeries-mgh-study-finds/2015-10-26


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  • (Score: 3, Interesting) by frojack on Tuesday October 27 2015, @10:18PM

    by frojack (1554) on Tuesday October 27 2015, @10:18PM (#255304) Journal

    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).

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