MGH: Medication Errors Report Points to Opportunities for Improvement

"A lot of initiatives" have been implemented at [Massachusetts General Hospital], "IT and otherwise, to address some of the failure modes that have been identified," says the senior vice president for quality and safety at the elite academic medical center.

A report identifying medication errors or adverse drug events during half of all perioperative periods at Massachusetts General Hospital provides an opportunity to make improvements and is not necessarily a cause for alarm, say clinicians at the renowned Boston-based hospital.

The study published in the October issue of Anesthesiology examined 277 operations at MGH between November 2013 and June 2014 and found that one-third of the errors resulted in adverse drug events or harm to patients.

"Studies like this allow us to develop solutions to eliminate that potential for harm," says lead author Karen C. Nanji, MD, of MGH's Department of Anesthesia, Critical Care & Pain Medicine.

"While every second operation did involve a medication error or an adverse drug event, fortunately all of these errors did not lead to patient harm. More than one third of the errors led to observed patient harm and the remainder had the potential for harm, ranging from less significant events to more serious harm like changes in vital signs or increased infection risk."

Elizabeth Mort, MD, an internist and senior vice president for quality and safety at MGH, concedes that media reports detailing potentially serious errors at the elite academic medical center "do catch your eye." But she says the emphasis should be on helping people understand the findings.

"Needless to say, I wouldn't have titled it that way," she says. "What you want to do is help people understand the complexity of healthcare in a way that is constructive. For me to see a well-designed articulation of errors anywhere in the institution to me is exciting because it gives us an opportunity to find ways to reduce those harms. In fact, there have been a lot of initiatives implemented at Mass General, IT and otherwise, to address some of the failure modes that have been identified in the paper."

For the Anesthesiology study, an in-house team of four researchers at MGH observed 225 anesthesia providers: anesthesiologists, nurse anesthetists, and resident physicians during 277 randomly selected operations conducted from November 2013 to June 2014. Throughout the perioperative process, the observers documented every medication administration, including any medication errors, defined as any kind of mistake in the process of ordering or administering a drug, or adverse drug event, defined as harm or injury to a patient related to a drug, whether or not it was caused by an error.

Overall, it was determined that 124 of the 277 observed operations included at least one medication error or adverse drug event.

Of the almost 3,675 medication administrations in the observed operations, 193 events, involving 153 medication errors and 91 adverse drug events, were recorded either by direct observation or by chart review. Almost 80% of those events were determined to have been preventable. One-third of the observed medication errors led to an adverse drug event, and the remainder had the potential to cause an adverse event.

Errors Identified
The most frequent errors were mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patient's vital signs, and documentation errors. Of all the observed adverse drug events and the medication errors that could have resulted in patient harm, four of which were intercepted by operating room staff before affecting the patient, 30% were considered significant, 69% serious and less than 2% life-threatening; none were fatal.

The overall medication error rate of around 5% was the same among anesthesiologists, nurse anesthetists and residents. Medication errors and adverse drug events were more common with longer procedures, especially those lasting longer than six hours and involving 13 or more medication administrations.

Now that the errors have been identified, Mort says steps are already underway at MGH to reduce them.

"Number one, I get a good survey of what is in place now and I have a good handle on that because I am in the know on that's going on in the perioperative arena," she says.

"Number two, we have ongoing surveillance as part of our quality and safety operations where we have experts go into the different parts of the organization, including the operating room, and observe. That is part of how we keep the place safe. It's not just the operating room. We go into ICUs, the emergency departments, and other places."

Mort says IT interventions and systematic programs play a key role in error reduction.

The Role of IT
"We use electronic medical records for the anesthesia documentation records. It is no longer a piece of paper with check marks. We use an electronic record where things are documented electronically," she says.

"We also use decision support, with prompts to remind anesthesiologists to do antibiotic administration when it is necessary for certain types of cases. We also have in our operating rooms storage containers where medications are organized and labeled so they can be accessed quickly and safely when needed. And when you take a vial out of the container we have labeling machines that let you bar code the medication when you take a syringe and take the medication out of vial. Again, IT [is used] to make the administration and labeling process safer. There are a lot of medications used in operations so you want to make sure that when you're picking a drug you're picking the right drug, and when you are labeling a drug you are labeling it correctly so that when you use a drug you have the right drug."

"We also do team training. We do simulations. We do universal protocol and time out," she says. "My question to the team is 'What do we do next?' That is the work going forward for folks on the perioperative team that are constantly building on what we have."

The study findings must be looked at as part of an ongoing process of quality improvements, Mort says.

"If you don't identify opportunities for improvement you won't improve," she says. "This work is important, and maybe it will encourage others to do similar types of inquiries or encourage hospitals to look under their own roof to see if the kinds of things that Karen found in her study are seen there. I am hoping that others will learn from it. That's why we do it."