Medication Errors Occur in 50% of Surgeries. Can Simulation Training Help?

Medication Errors Occur in 50% of Surgeries. Can Simulation Training Help?

By Roxanne Blanford


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A first of its kind study measured the incidence of medication errors and adverse drug events during the perioperative period found that some sort of mistake or adverse event occurred in 1 in 20 perioperative medication administrations. Every second operation resulted in a medication error and/or an adverse drug event (and in 5% of observed drug administrations), with one-third such errors resulting in direct harm to patients.

CAE Healthcare believes we should, and can, do better. But how?

 

Karen C. Nanji, MD, MPH, of the Massachusetts General Hospital (Department of Anesthesia, Critical Care & Pain Medicine), and lead author of the report stated: 

This is the first large-scale look at medication errors in the time immediately before, during and directly after surgery. But in my opinion, while there is much room for improvement, our results are not surprising."

It was back in 1999 that the Institute of Medicine (IOM) issued its now-famous report, "To Err is Human," bringing national attention to the need to stem rampant medical errors. The study recommended simulation-based training as a viable component in medical education for improving patient safety, supporting better clinical decision-making practices and for producing an increase in favorable outcomes.

Medical Error Statistics_ CAE Healthcare

Simulated patient care experience is an idea adapted from airline industry flight simulation training. Aviation has provided clear evidence for the contribution of individual and team errors to the occurrence of crashes and near misses. As a result of these studies, Crew Resource Management (CRM) curriculum for team training has become an integral and mandatory training standard in the aviation industry.

This pioneering work served as a model for the Anesthesia Crisis Resource Management course, which was one of the first applications of high-fidelity patient simulation in medicine.

                                                

Whether in airports, hospitals, or surgical rooms, certain fundamentals must be put in place to help to safeguard against medication error. These include:

  • better organization of charts and documentation of healthcare provider activities
  • rigorous safety checks, closed-loop communication, and follow-up mechanisms
  • team-based strategies to improve the quality, safety, and efficiency of patient care 
  • developing simulation training programs for realistically teaching students, so they are better prepared for real-life scenarios

The benefits of simulation training in healthcare continues to be proven. Not only are behaviors changed and improved, but no harm is done to any living patient while the learner masters essential skills. Patient safety benefits when simulation is included as part of training.

What other roles do you think patient simulation can play in reducing medical-related errors?


 

**The report, conducted at Massachusetts General Hospital (MGH), appeared in an October 2015 issue of the medical journal, Anesthesiology, the official journal of the American Society of Anesthesiologists, and was published online to coincide with the October 2015 ANESTHESIOLOGY® 2015 annual meeting in San Diego.