Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units

Abstract

Objective To examine medication safety in two ICUs and to assess the complexity of medication errors and adverse drug events (ADEs) in ICUs across the stages of the medication-management process. Methods Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (e.g., medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process. Results An average of 2.9 preventable or potential ADEs occurred in each admission, i.e., 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1,000 patient-days was 276, whereas the rate of preventable ADEs per 1,000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16–24% of potential and preventable ADEs, clusters of errors occurred either as sequence of errors (e.g., delay in medication dispensing leading to delay in medication administration) or grouped errors (e.g., route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process. Conclusions Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerized physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.

Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units

“…In one study, Rothschild et al (2005) found medications were responsible for 78% of serious errors in the ICU. Reported rates of ICU medication-related errors that either caused patient harm (i.e., preventable adverse drug events [ADEs]) or had the potential to cause patient harm (i.e., near misses) range from 9.2 to 12.8 per 1,000 patient-days and 116.8 to 276 per 1,000 patient-days, respectively (Carayon et al, 2014; Rothschild et al, 2005). Carayon et al (2014) found an average of 2.9 preventable or potential ADEs per ICU patient admission.…”

Medication Safety in Two Intensive Care Units of a Community Teaching Hospital After Electronic Health Record Implementation: Sociotechnical and Human Factors Engineering Considerations

“…medication errors and adverse drug events or ADEs) was based on the protocol of Bates and colleagues [26] and has been described in a previous publication [15]. We categorized medication safety events into:…”

How do community pharmacies recover from e-prescription errors?

“…Various patient safety researchers have employed concepts from human factors to study safety issues in healthcare settings. 23–25 …”