Hospitals Mess Up Medications in Surgery—a Lot

Yes, that was the inflammatory headline on Bloomberg Business News last week. It is great click-bait, but factually off base because the research it refers to was done at only one hospital.

Here's what the study found. During 277 operations with 3,671 medication administrations observed at the Massachusetts General Hospital, 193 (5.3%) involved a medication error or an adverse drug event. One or more errors or adverse drug events occurred in 124 (44.8%) of the procedures.

In all, 40 (20.7%) adverse drug events were not preventable—for instance, an allergic reaction to a drug that was not known about before. Of the remainder, “32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed adverse drug event and an additional 70 (45.8%) had the potential [emphasis added] for patient harm."

Sounds bad, but the Bloomberg article goes on to say "While all the errors observed in the study had the potential to cause harm, only three were considered [potentially] life-threatening, and no patients died because of the mistakes. In some cases, the harm lay in a change in vital signs or an elevated risk of infection."

The hospital's own press release, published on the science website EurekAlert, said this: "The most frequently observed errors were mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patient's vital signs, and documentation errors."

Mistakes in labeling syringes, occurring 24.2% of the time, were the most common type of error despite the presence of a bar code-assisted labeling system. This begs the question, how valuable is a bar code system that only prevents problems 75% of the time?

A website called FierceHealthcare took it up a notch saying, "While the research was conducted on procedures that took place at MGH, it indicates that similar failures happen at hospitals around the country."

It indicates no such thing. The paper actually says "our findings may not be generalizable to nonteaching hospitals." Or as is the case with most papers from a single institution, the results may not be generalizable to any other hospital.

Finally, the lead author of the study poured more gasoline on the fire with this comment, "Patients don’t need to go into surgery thinking that they’re going to have lasting permanent harm every second operation."

The study found nothing to suggest that 50% of patients suffered "lasting permanent harm." In fact, it isn't clear that any patients suffered lasting permanent harm, and most (66.7%) of the medication errors and adverse drug events were only potentially harmful.

Google “medication errors” and click on “News” for links to several more hand-wringing reports about the MGH study.

Although the paper and its accompanying media blitz may have overstated the severity of the problem, too many potentially harmful errors are occurring in the operating room and anesthesiologists need to clean up their act.