National Study on the Distribution, Causes, and Consequences of Voluntarily Reported Medication Errors Between the ICU and Non-ICU Settings*

Latif, Asad; Rawat, Nishi; Pustavoitau, Aliaksei; Pronovost, Peter J.; Pham, Julius Cuong

doi:10.1097/ccm.0b013e318274156a

Cited by 106 publications

(91 citation statements)

References 34 publications

(30 reference statements)

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“…Incidents in this stage of the medication process are common and must be confronted by professionals and health managers, especially in teaching hospitals, where safety culture -if implemented during the formation of health professionals -may result in changes in the health system. (6) Daytime was the period that presented a higher number of occurrences, similar to findings by national studies in intensive care units. This is related to the proportionally higher volume of drugs administered during this period.…”

Section: Discussionsupporting

confidence: 71%

“…This is related to the proportionally higher volume of drugs administered during this period. (6,7) It was observed that occurrences of medication-related incidents were associated with periods of hospitalization above 5 days, male patients and daily use of multiple doses of drugs. There is a consensus in several studies that prolonged hospital stays increase the exposure of patients to risks of being affected by incidents or failures during the care process and to the several environmental and intrinsic factors of a hospital environment.…”

Section: Discussionmentioning

confidence: 99%

“…(3,4) According to international studies, such incidents may affect up to 947 of 1,000 patients per day in intensive care units, increasing hospital costs up to $2.8 million. (5,6) In 2009 in Brazil, 305 medication-related incidents were identified in 44 patients hospitalized in an intensive care unit evaluated over a period of 30 days. (7) In this sense, intensive care units are identified as high-risk scenarios for medication-related incidents, whether due to the instability of the clinical condition of the patients or to the variability of situations and time pressure to which health care professionals are subjected, particularly nursing staff.…”

Section: Introductionmentioning

confidence: 99%

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Prevalência de incidentes relacionados à medicação em unidade de terapia intensiva

et al. 2015

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Objective: To estimate the prevalence of medication-related incidents in an intensive care unit. Methods: Cross-sectional study that included 116 records of hospitalizations within a 12-month period. The survey instrument was developed based on the study variables and was validated by two experts. The prevalence was calculated by considering the number of exposed hospitalizations as the numerator and the total of investigated hospitalizations as the denominator, calculating a 95% confidence interval. Fisher's exact test assuming maximum significance level of 5% (p<0.05) was used to verify significant association. Results: It was observed that 113 hospitalizations had been exposed to at least one type of incident, totaling 2,869 occurrences: 1,437 reportable circumstances, 1,418 no-harm incidents, 9 near-miss incidents and 5 adverse events. The incidents occurred during the prescription stage (45.4%) and the absence of information on the actions taken by the health professionals in relation to the incidents was identified in 99% of the records. Conclusion: Prevalence of 97.4% of medication-related incidents was estimated. ResumoObjetivo: Estimar a prevalência de incidentes relacionados à medicação em uma Unidade de Terapia Intensiva. Métodos: Estudo transversal que incluiu 116 registros de internações hospitalares no período de 12 meses. O instrumento de pesquisa foi elaborado com base nas variáveis de estudo e validado por dois experts. A prevalência foi calculada considerando o número de internações expostas como numerador e o total de internações investigadas como denominador, calculando intervalo de confiança de 95%. Para a verificação de associação significativa entre as variáveis, utilizou-se o Teste Exato de Fisher, assumindo nível de significância máximo de 5% (p<0,05). Resultados: Verificou-se que 113 internações foram expostas a pelo menos um tipo de incidente, totalizando 2.869 ocorrências, sendo 1.437 circunstâncias notificáveis, 1.418 incidentes sem dano, nove potenciais eventos adversos e cinco eventos adversos. Os incidentes aconteceram durante a fase da prescrição (45,4%) e a ausência de conduta dos profissionais de saúde frente aos incidentes foi identificada em 99% dos registros. Conclusão: Estimou-se prevalência de 97,4% incidentes relacionados à medicação.

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Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Prevalência de incidentes relacionados à medicação em unidade de terapia intensiva

et al. 2015

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“…However we acknowledge that the issue of the frequency of medical errors in the critical care setting is controversially discussed in medical literature [30,31] and our findings might also be influenced by other factors such as underreporting as a consequence of fear of punitive measures [32,33]. In our study, most administration errors occurred on the wards, where work under time pressure due to shortage of personnel and heavy workload are recognized risk factors [34].…”

Section: /22mentioning

confidence: 71%

Medication wrong route administration: a poisons center-based study

Bloch-Teitelbaum

Lüde

Rauber-Lüthy

et al. 2013

Expert Opinion on Drug Safety

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OBJECTIVES: To describe clinical effects, circumstances of occurrence, management and outcomes of cases of inadvertent administration of medications by an incorrect parenteral route. METH-ODS: Retrospective single-center consecutive review of parenteral route errors of medications, reported to our center between January 2006 and June 2010. We collected demographic data and information on medications, route and time of administration, severity of symptoms/signs, treatment, and outcome. RESULTS: Seventy-eight cases (68 adults, 10 children) were available for analysis. The following wrong administration routes were recorded: paravenous (51%), intravenous (33%), subcutaneous (8%), and others (8%). Medications most frequently involved were iodinated x-ray contrast media (11%) and iron infusions (9%). Twenty-eight percent of the patients were asymptomatic and 54% showed mild symptoms; moderate and severe symptoms were observed in 9% and 7.7%, respectively, and were mostly due to intravenous administration errors. There was no fatal outcome. In most symptomatic cases local nonspecific treatment was performed. CONCLUSIONS: Enquiries concerning administration of medicines by an incorrect parenteral route were rare, and mainly involved iodinated x-ray contrast media and iron infusions. Most events occurred in adults and showed a benign clinical course. Although the majority of exposures concerned the paravenous route, the occasional severe cases were observed mainly after inadvertent intravenous administration. Statement about prior postings and presentationsWe confirm that our paper is not under review by another journal.Part of the data was presented at the 13th Joint Annual Meeting of the German, Swiss, and Austrian Societies for Clinical Pharmacology and Toxicology, October 20-22, 2011, Zurich, Switzerland. Key words:Iatrogenic errors; medications; poisons centre; route of administration. 2/22 Abstract ObjectivesTo describe clinical effects, circumstances of occurrence, management and outcomes of cases of inadvertent administration of medications by an incorrect parenteral route. MethodsRetrospective single-centre consecutive review of parenteral route errors of medications, reported to our centre between January 2006-June 2010. We collected demographic data and information on medications, route and time of administration, severity of symptoms/signs, treatment, and outcome. Results78 cases (68 adults, 10 children) were available for analysis. The following wrong administration routes were recorded: paravenous (51%), intravenous (33%), subcutaneous (8%), and others (8%). Medications most frequently involved were iodinated x-ray contrast media (11%) and iron infusions (9%). 28% of the patients were asymptomatic and 54%showed mild symptoms; moderate and severe symptoms were observed in 9% and 7.7%, respectively, and were mostly due to intravenous administration errors. There was no fatal outcome. In most symptomatic cases local nonspecific treatment was performed. ConclusionsEnquiries concerning administration...

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“…The error resulted from either the traveler's or the pharmacist's misapprehension, where it was assumed that the prescription Preventable adverse drug events including prescription errors are an unfortunate but frequent occurrence in all healthcare scenarios: from intensive care units to ambulatory care. 7,8 Errors in prescription dosing or frequency constitute more than a quarter of all prescription errors in ambulatory care. 9 Serious prescription errors have also been documented in the treatment and prophylaxis of malaria.…”

Section: Discussionmentioning

confidence: 99%