Parenteral medication errors common in ICUs

In a multinational prospective study published in the BMJ, investigators demonstrated that parenteral medication errors are common occurrences in intensive care units (ICUs), but the number of errors can be reduced through the use of error-reporting and electronic prescribing systems.

The research group on quality improvement from the European Society of Intensive Care Medicine (ESICM) conducted this observational study using data from 113 ICUs in 27 different countries. Nurses and physicians on duty in participating units recorded data during their shifts over a 24-hour observation period. Medication errors were defined as errors of omission or commission, with 5 different types of errors identified: wrong dose, wrong drug, wrong route, wrong time, and missed medication. Type of drug administration and drug class were also recorded. The questionnaire that nurses and physicians filled out for each patient asked for factors contributing to the medication error (communication-written, communication-oral, handover, workload/stress/fatigue, experience/knowledge/supervision, violation of protocol/standard, recently changed brand name of drugs, equipment failure, or other), situational factors (admission/discharge, routine, emergency, movement within the hospital, intervention, urgent crisis in another patient, other), and grading of the error's effect (change registered or not, intervention necessary or not, no harm, temporary harm, permanent harm, or death). Data reporting was anonymous for patients and healthcare staff.

A total of 1,328 adult patients were included in the final study sample. Over the 24-hour observation period, 861 medication errors occurred in 441 patients (no errors, 67%; 1 error, 19%; >1 error, 14%); this translates to 74.5 errors per 100 patient-days (95% CI, 69.5–79.4). Of the 113 units in the study, 21 (19%) reported no medication errors during the observation period. The most common types of errors were wrong time of administration (n=386) and missed medication (n=259). Wrong dose (n=118), wrong drug (n=61), and wrong route (n=37) were less common. Workload/stress/fatigue was listed as a contributing factor in 32% of reported errors, followed by recently changed drug name (18%), communication-written (14%), and communication-oral (10%).

A stepwise multiple logistic regression demonstrated that the odds of a medication error of commission occurring were decreased when a critical incident reporting system was already in place at the unit (OR=0.34; 95% CI, 0.22–0.52; P<.01). The odds of a medication error of commission were increased, however, when infusions were previously prepared by a pharmacist (OR=2.36; 95% CI, 1.55–3.60; P<.01) rather than at the place where the medication would be administered. When an electronic prescribing system was used, the risk of an error requiring intervention was decreased significantly (OR=0.32; 95% CI, 0.16–0.64; P<.01).

The authors discussed several limitations of this study, including variations in unit organization and differences in communication and data collection. Volunteer bias may have also affected the results. The authors pointed out that even in light of these limitations, the study "shows that the administration of parenteral medication is a weak point in patients' safety in intensive care." They stated that it is "encouraging" that they found that "an existing critical incident reporting system was an independent predictor for a decreased risk of medication errors with respect to all types of error," adding, "Our results suggest that the implementation of several achievable measures might enhance the safe process of parenteral drug administration in intensive care units."

SOURCE

Valentin A, Capuzzo M, Guidet B, et al; on behalf of the Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM) and the Sentinel Events Evaluation (SEE) Study Investigators. Errors in administration of parenteral drugs in intensive care units: Multinational prospective study. BMJ. 2009;338:b814.