
Medication errors found in half of surgeries - DrScump
http://news.harvard.edu/gazette/story/2015/10/medication-errors-found-in-1-out-of-2-surgeries/
======
vpribish
"Of the almost 3,675 medication administrations in the observed operations,
193 events, involving 153 medication errors and 91 adverse drug events, were
recorded ... Almost 80 percent 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. Of
the adverse drug events that were recorded, 20 percent were not associated
with a medication error."

that tangle resolves to:

    
    
      3,675 observations
      122 (3.3%) preventable medication errors
      31 (0.8%) un-preventable errors
      18 (0.05%) adverse drug events not caused by medication error
    

3% preventable error rate is shocking - but does include things like
documentation problems as well as incorrect dosage

btw, the clickbait headline (which is Harvard's fault, not OPs) is seriously
getting in the way of communication since I went in to RTFA primed to find
garbage.

~~~
famousactress
Do you have experience in healthcare? 3% isn't shocking to me, in fact a
number of studies of IV med administration have error rates narrowly on either
side of 50% and serious error rates in the double digits. This report suggests
that you're safer in surgery than elsewhere in the hospital :|

I spent over a decade working on technology solutions to prevent medication
errors in hospitals but the bottom line problems that make it a hard problem
to solve are:

1\. There is a culture of individual blame and so (certainly most) errors go
un-reported at all. Systematic identification and process solution is still
not healthy, despite 16 years having passed since IOM did an admirable job
shining light on the problem [1]

2\. There isn't strong enough motivation to fix. It's easier to not report
medication errors than to fix them. You or someone you know has probably been
victim of a medication given in error one way or another. You just aren't
likely aware of it. Many errors aren't very serious, or result in lengthened
hospital stays (which guess what!? the responsible institution probably gets
paid for). Even the consequences of serious errors aren't often (maybe even
usually) attributed to the source mistake.

Like many things, money has driven the status quo (more money in ignoring than
acknowledging) and it'll drive the solution. Accountability and solutions to
this problem will come in the form of payers [your insurance company] finding
ways to measure and not reimburse for consequences of errors. Once that
motivation exists in a major way solutions will show up very quickly... it's a
non-trivial, but also sub-ridiculously-hard problem to solve, from a
process/technical perspective.

[Edit: I've been out of this problem space for 6-7 years now (because _fuck
selling things to hospitals_ [2]) so would love to hear from anyone who knows
whether things have changed significantly and my take is now wrong/dated.]

[1]
[https://iom.nationalacademies.org/~/media/Files/Report%20Fil...](https://iom.nationalacademies.org/~/media/Files/Report%20Files/1999/To-
Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf)

[2] Not that it isn't super profitable - particularly if you spend way more on
steak-dinner-sales than making shit that actually solves problems! An
ironically terrible/frustrating market for anyone who actually cares about
clinicians or patients, though.

~~~
vpribish
My background is hedge fund and consumer website management - not healthcare.
My ignorance aside* - your points, and solution seem right on.

It's surprising that in these lightly-regulated, profit-driven, fields we seem
to have set up effective processes for error reduction that are not standard
in medicine! In trading operations we made (successful) efforts to avoid
individual blame, track mistakes, record lessons learned, and continuously
develop the processes and systems -- all motivated by the client's money at
the end of the day though it was professional culture that was at work minute-
by-minute.

* if only...

~~~
famousactress
Is trading lightly regulated? Terrifying :) Even then I assume it's not hard
to arrive at a hard-dollar-ROI story that drove the improvements.

Medication errors end up being a bit of a staring contest: Obviously there's
the _potential_ for value in terms of outcomes that are costing someone
(payer) money.. but I think historically it's been a hard-enough problem to
solve and a hard-enough problem for payers (or anyone, really) to see. Kind of
a natural deadlock.

The problem has gotten some attention, though. The IMO study lit a fire, and
companies like the ones I worked for chased it down with an obviously vested
interest in shining a light on the problem. Bottom line is that hospitals
(maybe even most of them now?) buy shit to make this not happen anymore. I
wonder if the fashion around buying those things has waned though. I don't
really hear about buzz/movement in this space the way I used to, and I
severely doubt it's a Solved Problem yet.

Remaining (and super fundamental) problem is that it's way easier and cheaper
to sell hospitals garbage than it is to build great solutions (and even if you
build great solutions, it doesn't make them massively easier to sell to
hospitals).

So until there's some external measurement and accountability, the entire
problem space will be dominated by perception-management and not actually
moving needles that matter enough.

------
shanemhansen
My mom was recovering from surgery a few years back. She was in lots of pain.
I should mention that it was hard getting the time of day from doctors or
nurses about next steps (how did the surgery go, how long would we be at the
hospital, etc).

My mom gradually got quieter and went to sleep. I little while later they came
in and took her to the ICU. Turns out they had accidentally overdosed her on
narcotics and depressed her respiration to unacceptable levels.

The nurses and doctors were quite friendly for a couple hours after that. It
turns out that after a nurse almost kills a loved one you a small window of
decent service from hospital staff.

I have family members who have collectively lost years of their lives due to
bad medications and negligence, but they a) aren't the kind of people who sue
b) don't have the resources or willpower to do so even if they wanted to.

~~~
steveeq1
I don't get it, don't lawyers work for percentage? Any lawyer would take that
case as you described.

~~~
TeMPOraL
Maybe they didn't want to sue - maybe they believed it was just an accident
(shit happens), and without direct consequences to day-to-day life, they felt
suing _a hospital_ (and taking money & time out of system that generally helps
people) is kind of an assole thing to do?

I know I would feel like that even if I got almost killed by hospital staff,
but eventually recovered to full physical and mental capacity (if I ended up
somehow disabled or permanently ill, then it would be another story).

~~~
steveeq1
Then they would choose not to sue as a matter of principle, not because they
didn't not have the resources.

Not denying what you are describing as good reasons, I'm just saying that
listing "a lack of resources" a reason one can't sue in the United States is
false.

~~~
TeMPOraL
Fair enough. I don't much about the legal system in the US - so assuming you
can get a lawyer to work for % of settlement / damages, would that shield the
family from spending enormous amounts of time on the case? My impression was
that lawsuits are not only a money burner, but also a huge time sink.

~~~
jessaustin
Taking a medical malpractice case on contingency _to trial_ is a _huge_ risk
for a lawyer. Nearly every lawyer would be happy to hear your story, call up
the insurance company, and immediately settle for a pittance. (Hint: if you've
seen a "personal injury" lawyer in an ad, that's what he/she does.) Because of
student loans and other expenses, many lawyers are not in a position to do
anything else on contingency.

However, unlike most insurance policies, medical malpractice policies
typically include the services of defense attorneys who are happy to take a
case that isn't open-and-shut to court, rather than settling. Doctors make
lots of money, and they are happy to spend quite a bit as a business expense
to get _good_ insurance. Therefore plaintiff's attorneys in medical
malpractice have to be choosier about which cases they take. Any number of
factors can mean that a patient who really did suffer needlessly is not a good
risk for the lawyer. It totally _does_ make a difference if the plaintiff or
family can chip in for expenses along the way. The situation described by the
thread parent, in which the additional medical expenses caused by the
malpractice ended up being owed mostly to the hospital whose nurse made the
error, would probably be better handled by the hospital's accounts receivable
department than by the courts. (Although since the error was ascribed to a
nurse we might not expect the same blue-ribbon defense that a physician would
get.)

I once served on a jury who found for the defendant in a medical malpractice
case.

------
medymed
I will be looking for frequency of medication errors per medication. Giving
someone a triple dose of advil or local anesthetic probably not too big of a
deal, but a triple dose of phenylephrine or labetolol is asking for trouble.
In other words, I'm curious of the rate of scary mistakes versus meh-
don't-worry-about-it mistakes, though that terminology is not politically
acceptable. Explaining any difference there would be fascinating.

~~~
nommm-nommm
Is this bit from the article what you are looking for?

Of all the observed adverse drug events and medication errors that could have
resulted in patient harm — four of which were intercepted by operating room
staff before affecting the patient — 30 percent were considered significant,
69 percent serious, and less than 2 percent life-threatening; none were fatal.

------
Bud
From the article:

“Errors” were defined as any kind of mistake in the process of ordering or
administering a drug or an adverse drug event, which includes harm or injury
to a patient related to a drug, _whether or not it was caused by an error_.

~~~
belovedeagle
How else could they conduct this study? It would be completely meaningless if
observers had to second-guess after an observed harm or injury whether or not
it was an "error" or just bad luck. It makes no sense to catalogue
interactions which _could_ have caused harm (but may or may not have done so)
while ignoring the ones which _did_ cause harm (but weren't obviously errors).

~~~
johncolanduoni
Then the headline shouldn't call them all errors, if they do not have evidence
that they were in fact errors. "Medication errors or adverse reactions found
in 1 out of 2 surgeries" is a less sexy but actually accurate title.

~~~
cowsandmilk
80% of their "errors" were actual errors. So, the number drops to 1 out of 3
surgeries for "Preventable Medication Errors".

------
codingdave
As a patient, whether or not to have surgery is a tough decision. Surgery
really sucks. Even if everything goes as expected, they are cutting you up,
and putting you under drugs that mess with you so badly that you don't notice
them cutting you up. You spend at least a few days, if not weeks, recovering,
usually involving more drugs which come with side effects and addiction risk.

And that is when it goes right.

There are always small percentages thrown at you of the chance of possible
complications, so a 3% risk of a drug problem is another one to add to the
list. Even if there is a much higher chance of something going "wrong" during
the procedure, we're talking about a scenario where I am already trusting my
medical team to handle my body, deal with what happens, and bring me back to
the recovery room . So an "Oops, oh crap, better fix this." moment is not
shocking to me... I just assume it happens, and trust the doctors to react
appropriately.

But all of that risk and all of the problems with surgery ... you choose that
to fix what is usually a worse problem. For example, I once got to make the
decision to have a surgery that had a 97% chance of letting me walk again. And
today, I am walking.

Would it be great if there was a 0% chance of error? Of course! But I take it
much more as an area in which we can improve, not a shocking metric that would
scare me away from surgery.

------
chazu
Medication errors and adverse drug events are a terrifyingly common cause of
hospitalization and even death, especially in the elderly. Thankfully some
companies are really doing neat things to try and improve the quality of care
that elders receive. For example Carekinesis[1], one of my old employers, is
effectively engineering solutions to help new-school eldercare paradigms -
specifically PACE programs[2] - to decrease adverse drug events to nearly
zero.

If you haven't heard of PACE as an alternative model for elder care (as
opposed to long term care) I highly recommend you learn about it. The
statistics on its effectiveness versus LTC are astounding.

[1] [http://www.carekinesis.com](http://www.carekinesis.com) [2]
[https://en.wikipedia.org/wiki/Program_of_All-
Inclusive_Care_...](https://en.wikipedia.org/wiki/Program_of_All-
Inclusive_Care_for_the_Elderly)

------
TrevorJ
There's a list of common medications I can't take because of a fairly benign
condition I have, which is and has been in my medical records for years. 90%
of the time doctors prescribe me things I can't take, even though the
information is simple and at their fingertips. I can't imagine the number of
mistakes that must get made in more complex cases.

------
wilwade
And people wonder why I would prefer to have an IBM Watson powered robot
treating me. (Actually I would prefer the doctor required to work in
conjunction with Watson. So many simple errors would be caught).

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backtoyoujim
Now that is an industry ripe for disruption.

