Serious Parenteral Medication Errors Common in Intensive Care Units

Parenteral medication errors at the administration stage are common in intensive care units (ICUs) and may result in permanent harm or death, according to a new multinational study.

Researchers at the Medical University of Vienna (Austria) conducted a prospective, observational, cross-sectional study involving 113 ICUs from 27 countries. A total of 1,328 adult patients participated in the study, in which hospital staff self-reported medication errors in a single questionnaire for each participant. The study was designed to evaluate the frequency, characteristics, and contributing factors of parenteral medication errors at the administration stage in the ICU.

The researchers found that the total prevalence of parenteral medication errors at the administration stage in ICUs was 74.5 errors per 100 patient days. 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. Overall, 67% of the participants experienced no errors, 19% experienced 1 error, and 14% experienced more than 1 error. Errors were most frequently associated with wrong time of administration, followed by missed medication, wrong dose, wrong drug, and wrong route. 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. 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. The study was published first online on March 12, 2009, in the British Medical Journal (BMJ).

"One of the most important steps in improving patients' safety is to understand how and why errors occur," said lead author Andreas Valentin, M.D., of the department of emergency medicine. "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."

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Medical University of Vienna