Reported Medication Errors in ICU and Non-ICU Settings
Reported Medication Errors in ICU and Non-ICU Settings
Objective: To compare the distribution, causes, and consequences of medication errors in the ICU with those in non-ICU settings.
Design: A cross-sectional study of all hospital ICU and non-ICU medication errors reported to the MEDMARX system between 1999 and 2005. Adjusted odds ratios are presented.
Setting: Hospitals participating in the MEDMARX reporting system.
Interventions: None.
Measurements and Main Results: MEDMARX is an anonymous, self-reported, confidential, deidentified, internet-accessible medication error reporting program that allows hospitals to report, track, and share medication error data. There were 839,553 errors reported from 537 hospitals. ICUs accounted for 55,767 (6.6%) errors, of which 2,045 (3.7%) were considered harmful. Non-ICUs accounted for 783,800 (93.4%) errors, of which 14,471 (1.9%) were harmful. Errors most often originated in the administration phase (ICU 44% vs. non-ICU 33%; odds ratio 1.63 [1.43–1.86]). The most common error type was omission (ICU 26% vs. non-ICU 28%; odds ratio 1.00 [0.91–1.10]). Among harmful errors, dispensing devices (ICU 14% vs. non-ICU 7.1%; odds ratio 2.09 [1.69–2.59]) and calculation mistakes (ICU 9.8% vs. non-ICU 5.3%; odds ratio 1.82 [1.48–2.24]) were more commonly identified to be the cause in the ICU compared to the non-ICU setting. ICU errors were more likely to be associated with any harm (odds ratio 1.89 [1.62–2.17]), permanent harm (odds ratio 2.45 [1.17–5.13]), harm requiring life-sustaining intervention (odds ratio 2.91 [1.86–4.56]), or death (odds ratio 2.48 [1.18–5.19]). When an error did occur, patients and their caregivers were rarely informed (ICU 1.5% vs. non-ICU 2.1%; odds ratio 0.63 [0.48–0.84]) by the time of reporting.
Conclusions: More harmful errors are reported in ICU than non-ICU settings. Medication errors occur frequently in the administration phase in the ICU. When errors occur, patients and their caregivers are rarely informed. Consideration should be given to developing additional safeguards against ICU errors, particularly during drug administration, and eliminating barriers to error disclosures.
Interest in patient safety has accelerated since the publication of the Institute of Medicine's report, "To err is human" in 1999. This landmark report highlighted the fact that preventable medical errors account for between 44,000 and 98,000 deaths annually in the United States. It specifically targeted medication errors as a focus for preventative efforts. Medication errors are common and result in substantial harm and costs. Medication complications account for 19% of all medical errors, with injury ensuing in approximately 4%–6% of patients. Such errors were reported to add 2.8 million dollars in excess costs within a single tertiary care academic hospital.
One arena in which medication errors are particularly common is the ICU. The ICU is a perpetually changing environment where the care of critically ill patients often necessitates prompt decision making. Therefore, it is not surprising that the ICU is an error-prone setting in which adverse events can lead to serious disability. Factors hypothesized to contribute to medication errors in the ICU include the use of multiple medications per patient, the use of intravenous medications that require dose calculations, and the use of high-risk drugs associated with potentially severe adverse drug events. In addition, patients are frequently unable to provide an accurate history or help facilitate their care, a problem aggravated by a relatively large volume of patient transfers to and from the ICU.
The frequency of medication errors in adult ICUs is variable, ranging from 1.2 to 947 per 1000 patient-days, with a median of 105.9 per 1000 patient-days. The wide range of frequencies is likely due to study variability in definitions of medical error, error detection technique, and the type of ICUs involved in the study. Whereas one study suggests that medication error rates in the ICU are higher than those in non-ICUs, another suggests that they are equal.
A number of studies have reported the prevalence of medication errors in the ICU, but limited evidence is available regarding the cause(s) of these errors and whether these causes differ from those outside the ICU. The purpose of this study was to compare the distribution, causes, and consequences of medication errors in the ICU compared with those in non-ICU settings. We hypothesize that ICU medication errors are more likely to result in harm than those made in the non-ICU setting because the patients are more severely ill and have more complex medication regimens.
Abstract and Introduction
Abstract
Objective: To compare the distribution, causes, and consequences of medication errors in the ICU with those in non-ICU settings.
Design: A cross-sectional study of all hospital ICU and non-ICU medication errors reported to the MEDMARX system between 1999 and 2005. Adjusted odds ratios are presented.
Setting: Hospitals participating in the MEDMARX reporting system.
Interventions: None.
Measurements and Main Results: MEDMARX is an anonymous, self-reported, confidential, deidentified, internet-accessible medication error reporting program that allows hospitals to report, track, and share medication error data. There were 839,553 errors reported from 537 hospitals. ICUs accounted for 55,767 (6.6%) errors, of which 2,045 (3.7%) were considered harmful. Non-ICUs accounted for 783,800 (93.4%) errors, of which 14,471 (1.9%) were harmful. Errors most often originated in the administration phase (ICU 44% vs. non-ICU 33%; odds ratio 1.63 [1.43–1.86]). The most common error type was omission (ICU 26% vs. non-ICU 28%; odds ratio 1.00 [0.91–1.10]). Among harmful errors, dispensing devices (ICU 14% vs. non-ICU 7.1%; odds ratio 2.09 [1.69–2.59]) and calculation mistakes (ICU 9.8% vs. non-ICU 5.3%; odds ratio 1.82 [1.48–2.24]) were more commonly identified to be the cause in the ICU compared to the non-ICU setting. ICU errors were more likely to be associated with any harm (odds ratio 1.89 [1.62–2.17]), permanent harm (odds ratio 2.45 [1.17–5.13]), harm requiring life-sustaining intervention (odds ratio 2.91 [1.86–4.56]), or death (odds ratio 2.48 [1.18–5.19]). When an error did occur, patients and their caregivers were rarely informed (ICU 1.5% vs. non-ICU 2.1%; odds ratio 0.63 [0.48–0.84]) by the time of reporting.
Conclusions: More harmful errors are reported in ICU than non-ICU settings. Medication errors occur frequently in the administration phase in the ICU. When errors occur, patients and their caregivers are rarely informed. Consideration should be given to developing additional safeguards against ICU errors, particularly during drug administration, and eliminating barriers to error disclosures.
Introduction
Interest in patient safety has accelerated since the publication of the Institute of Medicine's report, "To err is human" in 1999. This landmark report highlighted the fact that preventable medical errors account for between 44,000 and 98,000 deaths annually in the United States. It specifically targeted medication errors as a focus for preventative efforts. Medication errors are common and result in substantial harm and costs. Medication complications account for 19% of all medical errors, with injury ensuing in approximately 4%–6% of patients. Such errors were reported to add 2.8 million dollars in excess costs within a single tertiary care academic hospital.
One arena in which medication errors are particularly common is the ICU. The ICU is a perpetually changing environment where the care of critically ill patients often necessitates prompt decision making. Therefore, it is not surprising that the ICU is an error-prone setting in which adverse events can lead to serious disability. Factors hypothesized to contribute to medication errors in the ICU include the use of multiple medications per patient, the use of intravenous medications that require dose calculations, and the use of high-risk drugs associated with potentially severe adverse drug events. In addition, patients are frequently unable to provide an accurate history or help facilitate their care, a problem aggravated by a relatively large volume of patient transfers to and from the ICU.
The frequency of medication errors in adult ICUs is variable, ranging from 1.2 to 947 per 1000 patient-days, with a median of 105.9 per 1000 patient-days. The wide range of frequencies is likely due to study variability in definitions of medical error, error detection technique, and the type of ICUs involved in the study. Whereas one study suggests that medication error rates in the ICU are higher than those in non-ICUs, another suggests that they are equal.
A number of studies have reported the prevalence of medication errors in the ICU, but limited evidence is available regarding the cause(s) of these errors and whether these causes differ from those outside the ICU. The purpose of this study was to compare the distribution, causes, and consequences of medication errors in the ICU compared with those in non-ICU settings. We hypothesize that ICU medication errors are more likely to result in harm than those made in the non-ICU setting because the patients are more severely ill and have more complex medication regimens.
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