Serious Parenteral Medication Errors Common in Intensive Care Units

Eurona Tilley

March 13, 2009

March 13, 2009 — Parenteral medication errors at the administration stage are common in intensive care units and may result in permanent harm or death, according to a multinational study published online March 12 in the British Medical Journal.

"The combination of complexity and the potential for great harm makes medicine, especially intensive care, even more fraught with risk than other high complexity areas such as aviation," explain Andreas Valentin, MD, from the Department of Emergency Medicine, Medical University of Vienna and the Rudolfstiftung Hospital, Medical Department II in Vienna, Austria, and colleagues. "Although patients' safety is increasingly recognized as an essential component in the practice of intensive care medicine, the complexity of processes and medical conditions dealt with makes the practice of this specialty vulnerable and prone to error."

The frequency of medication errors at the prescription and administration stages was previously reported in the first multinational sentinel events evaluation (SEE 1). Because these errors are associated with a high potential for serious harm, this current study, the second multinational sentinel events evaluation study (SEE 2) was designed to evaluate the frequency, characteristics, and contributing factors of parenteral medication errors at the administration stage in intensive care units. In addition, the effect of parenteral medication errors and the outcome of patients exposed to these errors were assessed.

SEE 2 was a prospective, observational, 24-hour, cross-sectional study involving 113 intensive care units from 27 countries. A total of 1328 adult patients participated in the study, in which hospital staff self-reported medication errors in a single questionnaire for each participant.

"A medication error at the administration stage was defined as an error of omission or commission in the context of parenteral drug administration that harmed or could have harmed a patient," Dr. Valentin and colleagues write. "We exclusively addressed medication errors that were attributable to five types of error during the stage of administration: wrong dose, wrong drug, wrong route, wrong time, missed medication." These errors were further classified according to the method of drug administration and the class of drug administered.

The total prevalence of parenteral medication errors at the administration stage in intensive care units was found to be 74.5 errors per 100 patient days (95% confidence interval [CI], 69.5 – 79.4). In addition, while 71% of errors resulted in no change in the patient's health status, 0.9% of the total study population experienced permanent harm or death as a result of errors in the administration of parenteral drugs in intensive care units.

Overall, 67% of the participants experienced no errors, 19% experienced 1 error, and 14% experienced more than 1 error. Nineteen percent of the intensive care units did not report any medication errors. Errors were most frequently associated with the wrong time of administration (n = 386) followed by missed medication (n = 259), wrong dose (n = 118), wrong drug (n = 61), and wrong route (n = 37). Medication errors at the administration stage were most likely to occur during routine situations (69%) and during intravenous bolus administration (9%). Furthermore, the administration of antimicrobial drugs and those in the class of sedation or analgesia were most frequently associated with errors.

Workload, stress, and fatigue were reported as the most frequent contributing factors to medication errors (32%). Other contributing factors included changes in drug names; written or oral miscommunication; lack of experience, knowledge, or supervision; violation of protocol; shift change; and equipment failure. More than half of the errors (53%) that resulted in permanent harm or death occurred in situations in which trainees were involved.

"One of the most important steps in improving patients' safety is to understand how and why errors occur," the authors emphasize. Several contributing factors to medication errors were identified in this study, but a causal relationship could not be confirmed due to the study's observational design. "Univariate and multivariate analyses showed that more severely ill patients, who receive a higher level of care with the corresponding increased use of parenteral medication, are more likely to experience a medication error. This finding directly reflects the complexity of care and thus the increased opportunity for error," Dr. Valentin and colleagues write.

A limitation of this study was that certain elements that influence the occurrence of errors were unable to be evaluated due to the 24-hour observational study design. These elements include variations in culture, communication, data collection, and organizational structure. Furthermore, because hospital staff members were self-reporting the occurrence of errors, there was a risk of underreporting. The nature of the study design could have also led to overreporting due to possible duplications in the questionnaire.

"Our results suggest that the implementation of several achievable measures might enhance the safe process of parenteral drug administration in intensive care units," the authors conclude. These include the standard verification of perfusors and infusion pumps at every nursing shift change, the use of a critical incident reporting system, a lower ratio of patients to nurses, improved supervision of trainees, as well as enhanced technical measures such as aided recall, clear drug identification, and proper design of infusion pumps.

The study was supported and funded by the Austrian Center for Documentation and Quality Assurance in Intensive Care Medicine and endorsed by the European Society of Intensive Care Medicine.

BMJ. Published online March 12, 2009.

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