Becker's Hospital Review

54 CARE DELIVERY Study: Medication Errors Occur in Half of All Surgeries By Shannon Barnet E ven at a prestigious academic medical center like Massa- chusetts General Hospital in Boston, medication errors and adverse drug events prove problematic. Recent research from MGH found some medication mistake or adverse event occurred in every other operation studied. e MGH study is the first to measure the incidence of med- ication errors and adverse drug events during the perioperative period. Researchers observed 225 anesthesia providers — includ- ing anesthesiologists, nurse anesthetists and resident physicians — during 277 operations conducted at the hospital from Novem- ber 2013 through June 2014. e researchers defined medication errors as any kind of mis- take in the process of ordering or administering a drug. ey de- fined adverse drug event as harm or injury to a patient related to a drug, independent of whether it was caused by an error. ey found: 1. Nearly half (124 out of 277) of the observed operations includ- ed at least one medication error or adverse drug event. 2. Of the almost 3,675 medication administrations in the ob- served operations, 193 adverse events were recorded, including 153 medication errors and 91 adverse drug events. Nearly 80 per- cent of those events were determined to have been preventable. 3. One-third of the observed medication errors led to an adverse drug event, and the remainder had the potential to cause an ad- verse event. Of the adverse drug events that were recorded, 20 percent were not associated with a medication error. 4. Mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patient's vital signs and documentation errors were the most frequently observed errors. 5. Of all the observed adverse drug events and the medication errors that could have resulted in patient harm, 30 percent were considered significant, 69 percent serious and less than 2 percent life-threatening; none were fatal. Operating room staff intercept- ed four adverse drug events or medication errors before they af- fected the patient. 6. In addition to errors that occurred during and right aer sur- gical procedures, the researchers observed some sort of mistake or adverse event in 5 percent of observed drug administrations. 7. Medication errors and adverse drug events were more likely to occur during longer procedures, particularly those lasting more than six hours and involving 13 or more medication administra- tions. "While the frequency of errors and adverse events is much higher than has previously been reported in perioperative settings, it is actually in line with rates found in inpatient wards and outpa- tient clinics, where error rates have been systematically measured for many years," said lead author of the study Karen Nanji, MD. "We definitely have room for improvement in preventing periop- erative medication errors, and now that we understand the types of errors that are being made and their frequencies, we can begin to develop targeted strategies to prevent them." n 10 Most Common Patient Complaints, Grievances With Hospitals By Heather Punke P atients are continually asking hos- pitals to be treated like people, according to Peter Pronovost, MD, PhD, director of the Armstrong Insti- tute for Patient Safety and Quality and senior vice president for patient safety and quality at Baltimore-based Johns Hopkins Medicine. Dr. Pronovost worked with Jan Hill, Johns Hopkins' patient relations direc- tor, to compile a "patient wish list," or the most common pieces of feedback from patient letters or surveys. The list was published in U.S. News & World Report. The following are the 10 items compiled by Ms. Hill and Dr. Pronovost, which they note should be used as a conversation starter in healthcare: 1. Sleep deprivation from clinicians com- ing to do tests and draw blood in the middle of the night. 2. Noisy nurses' stations that can inter- fere with sleep. 3. Personal belongings being lost. 4. Staff not knocking before entering the room, which can be interpreted as a sign of disrespect. 5. Not keeping whiteboards updated. Updated whiteboards allow patients to know who is caring for them. Patients would also appreciate a notebook where they can keep important information and take notes. 6. Lack of clear communication and not updating the patient or family members if the patient's condition changes. 7. Messy rooms where surfaces aren't wiped down, or the bathroom smells. 8. Feeling unengaged in their care or like they are not being listened to. 9. Lack of orientation to the room and hospital. Patients would like to know how to work the television and how to order food. 10. Lack of professionalism from hospital staff, especially when they are on break. "While you may be on your break, you are still a hospital employee and a reflec- tion of the hospital," the article reads. n

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