Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands

Abstract

Background Medication errors occur frequently in intensive care units (ICU). Voluntarily reported medication errors form an easily available source of information. Objective This study aimed to characterize prescribing, monitoring and medication transfer errors that were voluntarily reported in the ICU, in order to reveal medication safety issues. Setting This retrospective data analysis study included reports of medication errors from eleven Dutch ICU's from January 2016 to December 2017. Method We used data extractions from the incident reporting systems of the participating ICU's. The reports were transferred into one database and categorized into type of error, cause, medication (groups), and patient harm. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories. Based on the analysis, ICU medication safety issues were revealed. Main outcome measure The main outcome measure was the proportion of prescribing, monitoring and medication transfer error reports. Results Prescribing errors were reported most frequently (n = 233, 33%), followed by medication transfer errors (n = 85, 12%) and monitoring errors (n = 27, 4%). Other findings were: medication transfer errors frequently caused serious harm, especially the omission of home medication involving the central nervous system and proton pump inhibitors; omissions and dosing errors occurred most frequently; protocol problems caused a quarter of the medication errors; and medications needing blood level monitoring (e.g. tacrolimus, vancomycin, heparin and insulin) were frequently involved. Conclusion This analysis of voluntarily reported prescribing, monitoring and medication transfer errors warrants several improvement measures in these processes, which may help to increase medication safety in the ICU.

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis

“…7 They also encounter frequent medication changes, with many chronic medicines discontinued and acute medication commenced, [8][9][10] presenting a patient safety concern, 11 particularly at the point of transitions. 12 Medication errors (MEs) are common in adult ICU patients at the interface of transfer to the hospital ward, with MEs reported to occur in between 46% and 74% of patients. [13][14][15] The most commonly reported types of ME involve continuation of potentially inappropriate Systematic review medication, discontinuation of important chronic medication and inappropriate dose or route of administration.…”

“…ICU patients may experience a protracted recovery, further compounded by polypharmacy and care fragmentation 7. They also encounter frequent medication changes, with many chronic medicines discontinued and acute medication commenced,8–10 presenting a patient safety concern,11 particularly at the point of transitions 12…”

“… 7 They also encounter frequent medication changes, with many chronic medicines discontinued and acute medication commenced, 8–10 presenting a patient safety concern, 11 particularly at the point of transitions. 12 …”

Medication Administration Safety Practices and Perceived Barriers Among Nurses: A Cross-Sectional Study in Northern Nigeria

“…[8] In all of these, errors in the prescription and medication use constitute the most damaging errors. [10,11] Medication safety refers to preventing and managing medication errors, which are unintended mistakes in the medicine-use process caused by omissions or commissions, as well as other errors. [12] Safety in the processes and practices are necessary for the management of the medication pathway.…”

“…[ 8 ] In all of these, errors in the prescription and medication use constitute the most damaging errors. [ 10 , 11 ]…”