Study Highlights Dangers of Medication Errors in Operating Rooms

FORT LAUDERDALE, Fla. _ Sloppy hospital coordination, human mistakes and system woes cause thousands of needless medication errors before, during and after surgery, authors of a new study said Tuesday.

Drug errors related to surgery cause lingering harm to 5 percent of the victims _ compared to 1.3 percent in other medication mistakes _ including 12 percent of children, the study found. Researchers said the findings make a strong case for fast action.

“It’s beyond troubling. It’s the smallest, youngest patients who are most at risk,” said co-author Diane Cousins, vice president for patient safety at U.S. Pharmacopeia, a nonprofit group overseeing medicines.

The research goes beyond a landmark study in 1999 that found medical errors cause 44,000 to 98,000 needless deaths every year. The study analyzed more than 11,000 medication errors from 1998 to 2005 in U.S. operating rooms, outpatient surgery units, and preoperative and post-operative areas. Four errors were fatal.

Errors included: wrong drugs given, incorrect dosages, improper timing, incorrectly connected intravenous tubes or drugs not given at all.

In many errors, one unit of the hospital failed to pass key information while “handing off” patients to another unit, the study said.

Errors involving children were common because many drugs used today were never tested on children. As a result, correct dosages may be unclear or may have to be calculated based on the child’s weight, which can lead to math errors.

The authors recommended 47 steps to help hospitals reduce errors, including assigning a pharmacist to oversee surgery, creating more double-checking and urging manufacturers to improve prepackaged dosages and labels. But Cousins said major solutions such as electronic records and increased emphasis in medical education are long-term, expensive steps.

In South Florida for example, the tax-assisted North Broward Hospital District responded to a fatal medication mistake that came to light last month by initiating an outside review of drug-handling, Chief Executive Alan Levine said Tuesday.

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