NCPA - National Center for Policy Analysis


March 8, 2007

Young children are the most likely victims of surgery-related medication mistakes and poor communication as the patient moves from the operating room to recovery is the most likely culprit, according to a new study.

According to researchers:

  • Among patients undergoing surgery, the rate of harm was 5 percent -- much higher than is typical for medication errors; among children it was 12 percent.
  • Typical dangerous mistakes were failures to administer antibiotics before surgery, failures to note allergies, errors in setting pumps that dispense blood thinners or painkillers and giving overdoses to infants.
  • In several cases described in the report, poor penmanship, careless listening or bad arithmetic caused patients to get doses 10 or even 50 times as high as they should.

Problems typically arose when a patient was handed off from the preoperative team to the operating room to the recovery room to the regular ward nurses, says Diane Cousins, a health care specialist at the pharmacopeia and one of the authors.

There are 10,000 drugs in the marketplace, she says, and many have never been tested on children in clinical trials, so doses are often made by guesswork based on weight, involving conversion of pounds to kilograms, sometimes by nurses who are not pediatric specialists.

"These may be back-of-the-envelope calculations not checked by anyone," Cousins said, "and they are often in very tiny amounts -- milliliters -- and that in itself breeds errors."

Source: Donald G. McNeil Jr., "Medication Errors Are Studied," New York Times, March 7, 2007.

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