Towards patient safety: assessment of medication errors in the intensive care unit in a developing country’s tertiary care teaching hospital

Abstract

ObjectivesTo determine the incidence, causes, patterns and outcomes of medication errors (MEs) in the intensive care unit.MethodsThe ME reporting system was established using the principles based on prospective, voluntary, open, anonymous and stand-alone surveillance in a tertiary care teaching hospital located in southern India. MEs involving patients of either sex were included in the study, and the reporters were given the choice to remain anonymous. The analysis was carried out to determine the patterns, causes and outcomes of the reported errors and was discussed with healthcare professionals (HCPs) to minimise the recurrence of MEs.ResultsA total of 292 MEs were reported voluntarily among 5137 admitted patients and the incidence of MEs was 5.6%. Administration errors (n=143, 49%) were the most common type of MEs reported followed by prescription errors (n=56, 19%) and dispensing errors (n=43, 15%). Factors responsible for MEs were related to performance deficit of HCPs due to excessive workload, fatigue, unclear interpersonnel communications and patient-related factors, which accounted for 37.6%, 13.1%, 9.6% and 7.7%, respectively. The majority of the reported MEs had an outcome of category C and A, based on the National Coordinating Council for ME Reporting and Prevention (NCC MERP) outcome category scale, amounting to 42.2% and 41.7%, respectively.ConclusionsAlthough the majority of MEs that reached the patients did not cause any harm, providing continuous education and awareness of MEs to HCPs and patients may minimise the scope of the factors that may contribute to MEs and improve overall patient safety.

Pharmacist-Initiated Medication Error-Reporting and Monitoring Programme in a Developing Country Scenario

“…HCPs regularly sacrifice their breaks to provide patient care, therefore during the night shifts bright lights, rest breaks, power naps, and exercises, can be used to provide relief from the symptoms of fatigue. To reduce distractions and improve interpersonal communications, CPOE systems can be employed and thus improving patient safety [41].…”

Sleep deprivation and medication administration errors in registered nurses—A scoping review

“…Fathi et al. (2017) noted that fatigue caused by excessive work was the most common cause of error, and Chalasani and Ramesh (2017) and Abdar et al. (2014) the second most common.…”

“…When a quantitative comparison was made with other factors, two studies found lack of sleep and/or fatigue was the most frequent cause of error (Fathi et al., 2017; Gorgich et al., 2016). A further seven studies found lack of sleep and/or fatigue to be within the top three causes of error (Abdar et al., 2014; Chalasani & Ramesh, 2017; Deans, 2005; Di Simone et al., 2020; Härkänen et al., 2018; Haw et al., 2005; Thomas et al., 2017).…”

“…(n = 2) (Chalasani & Ramesh, 2017;Deans, 2005) were the next most frequently used, followed by the Iranian nurses' medication questionnaire (n = 1) (Abdar et al, 2014), American society of health system pharmacist guidelines (n = 1) (Bellebaum, 2008), Wakefield et al (2005) medication error questionnaire (n = 1) (Bolandianbafghi et al, 2017) and a tool that considered a variation of 10% from intravenous industry standards to be an error (n = 1) (Parshuram et al, 2008).…”

“…However,Chaiard et al (2018) found that while errors were more common in RNs with less sleep, the overall results were not significant and sleep duration did not increase the risk of occupational errors Fathi et al (2017). noted that fatigue caused by excessive work was the most common cause of error, andChalasani and Ramesh (2017) andAbdar et al (2014) the second most common Deans (2005). considered fatigue and lack of sleep together and found that these human factors contributed to 16% of the errors.…”