Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: An observational study

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Summary

Objective

To determine the frequency of medication errors that occurred during the preparation and administration of IV drugs in an intensive care unit.

Setting

The study was conducted in a 12-bed intensive care unit of one of the largest teaching hospitals in Tehran.

Design

Data were collected over 16 randomly selected days at different medication round times, between July and September 2006. A trained observer accompanied nurses during intravenous (IV) drug rounds.

Medication errors were recorded during the observation times of IV drug administration and preparation. Drugs with the highest rate of use in the intensive care unit (ICU) were selected. Details of the process of preparation and administration of the selected drugs were compared to an informed checklist which was prepared using reference books and manufacturers’ instructions.

Results

We observed a total of 524 preparations and administrations. The calculated number of opportunities for error was 4040. The number of errors identified were 380/4040 (9.4%). Of those, 33.6% were related to the preparation process and 66.4% to the administration process. The most common type of error (43.4%) was the injection of bolus doses faster than the recommended rate. Amikacin was involved in the highest rate of error (11%) among all the selected medications. It was found that the IV rounds conducted at 9:a.m. had the highest rate of error (19.8%). No significant correlation was found between the rate of error and the nurses’ age, sex, qualification, work experience, marital status, and type of working contract (permanent or temporary).

Conclusions

Since our system is devoid of a well-organized reporting system, errors are not detected and consequently not prevented. Administrators need to take the initiative of developing systems that guarantee safe medication administration.

Introduction

Medication errors are defined as “any preventable event that may cause or lead to an inappropriate medication use or patient harm while in the control of the health care professional, patient or consumer”.1 It is estimated that 1–2% of patients admitted to hospitals in the U.S.A. are harmed as a consequence of medication errors.2 These errors are also a major cause of adverse events.3 Each error can result in an estimated $5000 in costs, not including legal expenses.3 Less is known about the medication errors in other parts of the world,4 including the Middle East.

Medication administration error rates have been used by researchers studying different drug distribution systems.5 Research on the impact of automated drug dispensing on the rate of error has shown that errors have not been omitted by advances in technology.6 Errors can occur in the process of drug prescribing, dispensing and administration. Medication administration errors are most often made by nurses administering medications on the patient care unit.7 However, dedicating nurses to medication administration has been shown not to affect medication error rates.8 The number of unintended events including medication errors during different shifts was reported by Capuzzo et al.9 Personal neglect (86.1%), intense workload (37.5%) and new staff (37.5%) were the three leading factors in medication errors considered by nurses in a survey. The need to solve other problems while administering drugs, advanced drug preparation without rechecking, and new graduates were listed as the top three causes in administration errors in another study.6

Tang et al. found that medical wards (36.1%) and intensive care units (33.3%) were the two most error-prone places of all hospital wards.6 Medication errors occur more commonly in intensive care units (ICUs) because patients in an ICU receive a larger number of medications. Critically ill patients also call for high-intensity care and may be at high risk of iatrogenic harm since they are severely ill.10 Studies have indicated, the more medications prepared and administered and the longer the hospital stay, the higher the risk of error. An overview of intravenous-related medication administration errors during a 5-year period, reported IV medication errors were 73,769 with harm resulting from 2.92 to 5.03% of these events. These errors primarily included improper concentration, and mistakes in calculations.11 In another study, Lisby et al., found that 41% of opportunities for administration errors resulted in errors.12

Medication preparation poses one of the greatest opportunities for error. Product preparation involves many steps and it is imperative that proper procedure is followed to avoid error and risk to the patient. In a study evaluating medications errors in UK, French and German hospitals, the wrong diluent was utilized in 1, 18 and 49% of doses administered in each hospital, respectively.13

Perhaps one of the most severe adverse events that can occur as a result of medication error is one that involves the intravenous (IV) route of administration. IV is the most common route of drug administration in the critical care setting; therefore this population is at high risk for adverse drug events.14 One study estimated about one-half of medication errors occurred in IV preparations and administrations, 1% of which resulted in severe adverse events.15

Currently, in our institution, IV medications are prepared by the nurses in the wards and; pharmacists are not involved in medication preparation. Nurses in our institution have minimal training in IV medication preparation. There is no mechanism for checking preparations in place. Each nurse is responsible for two ICU patients. We wanted to identify any error in medication preparation and/or administration, so that a system of safe medication preparation can be justified in our institution. The objective of this study was to determine the frequency, and types of errors which occur in preparation and administration of commonly used IV medications in an ICU of a teaching hospital.

Although a variety of methods have been utilized to investigate medication administration errors (MAEs), the observation-based method developed 40 years ago by Barker and McConnell16 is generally accepted as the most reliable and often-cited.17

Section snippets

Methods

The investigation was conducted in one of the largest teaching hospitals in Tehran with 446 inpatient beds. The study was conducted from July to September 2006. Medication distribution is centralized and there is no floor-based decentralized pharmacist currently available in our ICU. The ICU is a 12 bed, multidisciplinary ICU including pulmonary, cardiothoracic surgery, medical critical care, nephrology and anesthesiology with dedicated nursing staff. Average length of stay is 5 days and

Results

Five hundred and twenty-four preparations and administrations were witnessed by the observer. Of the 32 most commonly prescribed medications which were observed in the ICU, 22 had at least one error observed during preparation and/or administration. No errors were recorded for the rest of the 10 drugs. A total number of 4040 opportunities for error were calculated, of which 380 (9.4%) errors were detected. Among all errors made, 66.4% were related to administration and 33.4% to preparation

Discussion

The results of the present study indicate a relatively high rate of error in the preparation and administration of commonly used IV medications in our ICU. The high percentage of identified errors must be viewed in light of the detailed and systematic examination of errors and types of error at each stage of the medication process. Lisby et al., found that 41% of opportunities for administration errors resulted in errors.12 We found 9.4% of the opportunities resulted in an error. Variables such

Acknowledgment

We would like to thank the ICU staff for their assistance during data collection.

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