I've mentioned before that anesthesiologists are notorious for not being completely truthful on their anesthesia records. During an operation, the only person continuously keeping track of a patient's vital signs is the anesthesiologist. This has led to anesthesia records that are suspiciously too perfect. How can a patient undergoing open AAA repair have vital signs that barely deviate during the entire case? Yet I've seen records from other anesthesiologists that look exactly like railroad tracks stretching across the state of Kansas.
Now that many anesthesia records have moved into the digital realm, the opportunity to fudge the vital signs are more limited. The computer records every number, good or bad. Yes one can go back and change the measurements to their liking, but the computer documents that a change has occurred, and who changed it. At last, anesthesia records that are true to life.
But apparently not quite. Clever, or deceitful, anesthesiologists have still found ways to lie on their records. A study out of the University of Michigan shows that anesthesiologists are still trying to cover their asses on their records. The authors examined 434,554 records at the university from 2006-2015. Out of that huge database, they found that there were only 238 self reported medication errors. That works out to just 5.5 errors per 10,000 patients. The researchers are incredulous that such a small rate of medication errors really happened. By comparison, a study in the Canadian Journal of Anesthesia in 2012 found a reported medication error rate of one per 203 anesthesia records.
The most common medication error in the Michigan study was poor judgement, such as giving a drug that the patient is allergic to. The second most common error was giving the wrong drug. The errors caused almost ten percent of patients temporary harm, including prolonged intubation, unplanned admission to the hospital, or cancellation of the case.
So is this a problem isolated to the University of Michigan? It's highly likely that many institutions face the same issue. The authors suggest that anesthesiologists should be encouraged to be more forthcoming with their medical errors. An institution that wants more open communication without fear of retribution would greatly aid in identifying costly errors that lead to unnecessary patient suffering. Good luck with that.
The lower rates is the correct one perhaps?ReplyDelete
Decades ago if any adverse event occurred the record managed to "disappear."ReplyDelete