Frequency and Determinants of Drug Administration Errors in the Intensive Care Unit

University of Groningen, Groningen, Groningen, Netherlands
Critical Care Medicine (Impact Factor: 6.31). 05/2002; 30(4):846-50. DOI: 10.1097/00003246-200204000-00022
Source: PubMed


The study aimed to identify both the frequency and the determinants of drug administration errors in the intensive care unit.
Administration errors were detected by using the disguised-observation technique (observation of medication administrations by nurses, without revealing the aim of this observation to the nurses).
Two Dutch hospitals.
The drug administrations to patients in the intensive care units of two Dutch hospitals were observed during five consecutive days.
A total of 233 medications for 24 patients were observed to be administered (whether ordered or not) or were observed to be omitted. When wrong time errors were included, 104 administrations with at least one error were observed (frequency, 44.6%), and when they were excluded, 77 administrations with at least one error were observed (frequency, 33.0%). When we included wrong time errors, day of the week (Monday, odds ratio [OR] 2.69, confidence interval [CI] 1.42-5.10), time of day (6-10 pm, OR 0.28, CI 0.10-0.78), and drug class (gastrointestinal, OR 2.94, CI 1.48-5.85; blood, OR 0.12, CI 0.03-0.54; and cardiovascular, OR 0.38, CI,0.16-0.90) were associated with the occurrence of errors. When we excluded wrong time errors, day of the week (Monday, OR 3.14, CI 1.66-5.94), drug class (gastrointestinal, OR 3.47, CI 1.76-6.82; blood, OR 0.21, CI 0.05-0.91; and respiratory, OR 0.22, CI 0.08-0.60), and route of administration (oral by gastric tube, OR 5.60, CI 1.70-18.49) were associated with the occurrence of errors. In the hospital without full-time specialized intensive care physicians (which also lacks pharmacy-provided protocols for the preparation of parenteral drugs), more administration errors occurred, both when we included (OR 5.45, CI 3.04-9.78) and excluded wrong time errors (OR 4.22, CI 2.36-7.54).
Efforts to reduce drug administration errors in the intensive care unit should be aimed at the risk factors we identified in this study. Especially, focusing on system differences between the two intensive care units (e.g., presence or absence of full-time specialized intensive care physicians, presence or absence of protocols for the preparation of all parenteral drugs) may help reduce suboptimal drug administration.

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Available from: Toine Egberts
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    • "As in other investigations of AEs in the ICU, we had no “gold-standard” method to detect AEs. The use of external observers [8,19,21] may be considered a reference method for capturing AEs, but this strategy appears to consume a large number of resources and suffers from the Hawthorne effect. The AE self-reporting method provides a detailed description of the AE and identifies a large number of preventable incidents, but it has the risk of selection bias, underreporting and some degree of Hawthorne effect, whereas retrospective medical chart review provides less contextual information for an AE and identifies fewer preventable incidents. "
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    ABSTRACT: Background Adverse events (AEs) frequently occur in intensive care units (ICUs) and affect negatively patient outcomes. Targeted improvement strategies for patient safety are difficult to evaluate because of the intrinsic limitations of reporting crude AE rates. Single interventions influence positively the quality of care, but a multifaceted approach has been tested only in selected cases. The present study was designed to evaluate the rate, types, and contributing factors of emerging AEs and test the hypothesis that a multifaceted intervention on medication might reduce drug-related AEs. Methods This is a prospective, multicenter, before-and-after study of adult patients admitted to four ICUs during a 24-month period. Voluntary, anonymous, self-reporting of AEs was performed using a detailed, locally designed questionnaire. The temporal impact of a multifaceted implementation strategy to reduce drug-related AEs was evaluated using the risk-index scores methodology. Results A total of 2,047 AEs were reported (32 events per 100 ICU patient admissions and 117.4 events per 1,000 ICU patient days) from 6,404 patients, totaling 17,434 patient days. Nurses submitted the majority of questionnaires (n = 1,781, 87%). AEs were eye-witnessed in 49% (n = 1,003) of cases and occurred preferentially during an elective procedure (n = 1,597, 78%) and on morning shifts (n = 1,003, 49%), with a peak rate occurring around 10 a.m. Drug-related AEs were the most prevalent (n = 984, 48%), mainly as a consequence of incorrect prescriptions. Poor communication among caregivers (n = 776) and noncompliance with internal guidelines (n = 525) were the most prevalent contributing factors for AE occurrence. The majority of AEs (n = 1155, 56.4%) was associated with minimal, temporary harm. Risk-index scores for drug-related AEs decreased from 10.01 ± 2.7 to 8.72 ± 3.52 (absolute risk difference 1.29; 95% confidence interval, 0.88-1.7; p < 0.01) following the introduction of the intervention. Conclusions AEs occurred in the ICU with a typical diurnal frequency distribution. Medication-related AEs were the most prevalent. By applying the risk-index scores methodology, we were able to demonstrate that our multifaceted implementation strategy focused on medication-related adverse events allowed to decrease drug related incidents.
    Full-text · Article · Nov 2012 · Annals of Intensive Care
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    • "Several factors have been mentioned in the literature as potential causes for the high incidence rates of medication administration errors in adult critical care settings. Patients in ICU usually receive more drugs than those in general wards, and the majority of these drugs are given parenterally (Van Den Bemt et al., 2002). Studies have already shown that medication administration errors are more likely to occur in the parenteral route of administration, including the intravenous one, compared with other routes such as the oral route (Wirtz et al., 2003). "
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    ABSTRACT: Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high-risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings. This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. SEARCH STRATEGIES (INCLUSION AND EXCLUSION CRITERIA): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer-reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant. The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.
    Full-text · Article · Jul 2012 · Nursing in Critical Care
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    • "Seeking for root causes of critical incidents and elucidating the interactions among contributing factors that lead to them are necessary for developing effective prevention strategies. Attention distractions, high personnel workload, lack of drug knowledge and mathematical skills, and communication deficiencies have been reported as primary factors contributing to medication errors [11-13]. Since critical incidents constitute a broader field than errors, many other factors are expected to favor their occurrence, such as inadequate training about equipment use, lack of equipment checks, faulty material use, decreased patient surveillance, and so on. "
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    ABSTRACT: Despite their difficult definition and taxonomy, it is imperative to study critical incidents in intensive care, since they may be followed by adverse events and compromised patient safety. Identifying recurring patterns and factors contributing to critical incidents constitutes a prerequisite for developing effective preventive strategies. Self-reporting methodology, although widely used for studying critical incidents, has been criticized in terms of reliability and may considerably underestimate both overall frequency and specific types of them. Promotion of non-blaming culture, analysis of critical incident reports and development of clinical recommendations are expected to minimize critical incidents in the future.
    Full-text · Article · Jan 2012 · Critical care (London, England)
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