Study Finds Widespread Medication Errors During Surgery

ByABC News via logo

March 6, 2007 — -- Surgery patients are three times more likely to experience a harmful medication error than patients anywhere else in the health care system, according to a study released this morning.

United States Pharmacopeia, a nonprofit agency that examines and sets standards for pharmaceutical use, looked at the 11,000 medication errors in the last seven years. The study was the the largest ever on medication errors made in hospitals before, after and during surgery.

All of the mistakes involved health care workers giving patients the wrong amount of medicine or the wrong medicine altogether.

One of those victims was 1-week-old Dawn Jeffries. She was one of six premature babies accidentally given an adult dose of the blood thinner Heparin at an Indianapolis hospital.

"My baby was fine before they gave her the Heparin," said Heather Jeffries, Dawn's mother.

The problem was a mix-up of nearly identical vials of medicine. Fortunately, baby Dawn survived.

But the kind of mistake that sickened her is not uncommon -- 1.5 million patients suffer from mistakes with the medicine they're given every year, according to the Institute of Medicine.

"They are likely to cause harm probably at a higher rate than any other error," said Dr. Wilson Pace of the University of Colorado Medical School.

For adults, mistakes with medicine occur most often in the operating room. Most often, they are given the wrong drugs or not given antibiotics in time to prevent infection.

For children, mistakes most often happen in the recovery room, where 20 percent of the errors had harmful effects. Nearly as many mistakes with childrens' medicine were made in the operating room.

"Children are at particular risk because doses need to be calculated," said Diane D. Cousins of U.S. Pharmacopeia.

The authors of the report believe at least one problem is that there is no single person tracking patients' medications as they are shuttled from room to room during the surgical process.

But medical experts say it's unrealistic to assign one person to a patient and stay with the patient to monitor medications through the whole process.

They say a better solution would be electronic medical records that nurses could constantly access to be sure the meds are correct.

In the meantime, what should a patient or parent do?

Ask questions every time you or your child are given medicine, and ask about dosage. It's important. And be sure to bring an up-to-date list of all the medications you take to the hospital, including information on how often you take the medication and any allergies you have. That list should always be with your medical chart.

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