Medication Errors Happen in 50% of Surgeries*. Is Simulation the Solution?

| Roxanne Blanford

Simulation-based training continues to prove its value as a reliable factor in the quest to reduce medical-related errors and help make healthcare safer.

A first of its kind study1 measured the incidence of medication errors and adverse drug events during the perioperative period. Results determined that some sort of mistake, or adverse event, occurred in 1 in 20 perioperative medication administrations.

The most frequently observed errors were mistakes in labeling, incorrect dosage, and neglecting to treat a problem indicated by the patient’s vital signs.

Almost 80 percent of these events were determined to have been preventable.

 

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

Train Better Today with Healthcare Simulation

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. We definitely have room for improvement in preventing perioperative 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."

Simulation Training's Role in Reducing Medical Error

Simulation is a powerful tool to support the continuous improvement process of the healthcare system, leading to clinical competency and enhanced patient safety.
 
The advantage of simulation for continuous quality and process improvement resides in how healthcare simulation offers opportunities for clinicians to engage in repetitive, deliberate practice with no risk of patient harm.

Properly regulated simulation has proven itself, again and again, to be an effective way to develop medical staff, improve knowledge, skills and clinical behaviors through a training modality that does not directly involve patients. "By integrating human factors, simulation seems to be effective in preventing iatrogenic risk related to medication errors if the program is well designed."2

Learning within a risk-free environment allows for non-fatal mistakes, wherein learners get to try and try again until proficiency and mastery are attained. 

It is important to note that medical errors are not just the result of one individual making a mistake. Systems and processes wherein humans work and interact require constant diligence to achieve any sustainable improvement in quality. The impetus must start from within, by addressing systemic weaknesses and working to correct them. 

Here are a few fundamentals that clinicians and patient care staff may adopt to achieve continuous process improvement and foster a stronger culture of patient safety.  

  • Make safety a priority at the highest level 

  • Learn from mistakes rather than deny they happen

  • Verify the identity of the patient before proceeding

  • Get confirmation on anything that seems unclear (Speak Up)

  • Closely adhere to safety checks and follow-up protocol

  • Encourage reporting of patient safety events and near misses 

  • Utilize simulation training to promote effective team behaviors, communication and critical thinking

CAE Healthcare's vision is to advance healthcare practices and improve patient outcomes. Our mission is to be the worldwide training partner of choice to identify needs and implement tailored solutions towards improving safety and outcomes in healthcare.

 

See how CAE can help you advance a culture of patient safety through healthcare simulation.

 

 

 

 

 

 

 

 

 

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Sources:

In the News: Medication Errors in 50% of Surgeries. Wolters Kluwer Clinical Drug Information, Inc https://www.wolterskluwercdi.com/blog/med-errors-surgery/

1The 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

2Sarfati L, Ranchon F, Vantard N, et al. Human-simulation-based learning to prevent medication error: a systematic review. J Eval Clin Pract. 2019;25:11-20.

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