Surgery patient overdosed when accidentally given 10x the intended dose of anesthesia – doctors didn’t notice anything until it was too late

Tuesday, January 30, 2018 by

The Mayo Clinic recently came under fire as a male senior patient suffered a ketamine overdose following a medical error, the Daily Mail reported. According to the report, the patient who is in his 60s had an overdose after an anesthesiologist accidentally took a more concentrated bottle of ketamine to sedate him. The patient allegedly received 950 milligrams of intravenous ketamine instead of 95 mg, which was up to 10 times the intended amount.

The patient underwent surgery for sleep apnea, a disorder in which breathing repeatedly stops and starts while asleep. The report noted that the specific procedure performed on the patient remains unclear. The report also stated that the doctors were not able to observe any signs of medical error after ketamine was administered until the patient took a longer time to wake up. Likewise, the patient allegedly did not show signs of overdose effects — such as lack of blood flow or any central nervous system disruptions — following ketamine administration.

The report noted that sleep apnea is a prevalent condition in the United States, which affected about 22 million Americans. The most common surgery for sleep apnea involved removing excess tissue in the throat in order to widen the airway. Other sleep apnea surgeries may even require the removal of tonsils.

Study: Medical error is now the third leading cause of death in the U.S.

The recent case added to a growing number of recorded medical blunders over the years. In fact, a 2016 study carried out by researchers at the Johns Hopkins University School of Medicine revealed that medical error was the third leading cause of death following heart disease and cancer. The experts reviewed medical death rate data over an eight-year period and found that medical errors were associated with more than 250,000 deaths per year in the U.S. (Related: Medical errors are killing at least 200,000 people per year in America.)

“Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics. The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used,” said Dr. Marty Makary, a Johns Hopkins surgeon and health reform expert.

“Unwarranted variation is endemic in health care. Developing consensus protocols that streamline the delivery of medicine and reduce variability can improve quality and lower costs in health care. More research on preventing medical errors from occurring is needed to address the problem,” Dr. Makary concluded.

In line with the findings, Dr. Makary wrote an open letter to the Centers for Disease Control and Prevention (CDC) that urged the health agency to change the way it collects the country’s national vital health statistics each year. The expert stressed that the current measures in generating patient statistics had a serious limitation that was caused by an old policy, which stated that death certificates can only be tabulated with an international classification of diseases (ICD) billing code.

“We suggest that the CDC allow clinicians to list medical error as the cause of death, and, in the interim, the CDC should list medical error as the third most common cause of death in the U.S. It is time for the country to invest in medical quality and patient safety proportional to the mortality burden it bears. This would mean research in technology that reduces harmful and unwarranted variation in medical care, the non-technical (behavioral) and communication skills that prevent harm, ways to improve the diagnostic accuracy, and the prevention before and rescue after a preventable adverse event,” the open letter read.

The findings were published in The BMJ.

Sources include:

DailyMail.co.uk

HopkinsMedicine.org

Assets.DocumentCloud.org [PDF]



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