Drug errors ‘common’ in intensive care units

Researchers say they have discovered an alarming rate of injected medication errors in intensive care units in Britain and Europe.

Dr Andreas Valentin of Rudolfstiftung Hospital, Vienna, Austria, and colleagues looked at errors made at 113 intensive care units in 27 countries, including 17 in the UK.

A total of 1,328 adult patients were involved. During the study, 861 errors were reported affecting 441 patients. This equates to 74.5 events per 100 patient days, the team report on the website of the British Medical Journal.

“Three quarters of the errors were classified as errors of omission,” they write. “Twelve patients, or 0.9 per cent, experienced permanent harm or death.” Trainees were involved in eight of these 12 cases.

Errors were commonly linked to wrong time of administration, missed medication, followed by wrong dose, wrong drug, and wrong route of administration.

They were more likely when the patient was experiencing organ failure, when they needed intravenous medication, when more than one drug was prescribed, at larger intensive care units, when there were more patients per nurse, and when the units were busy.

Basic monitoring reduced the risk, as did critical incident reporting systems and an established routine of checks at nurses’ shift change.

The researchers conclude: “Parenteral [injected] medication errors at the administration stage are common and a serious safety problem in intensive care units.” They appear to represent “a common pattern of weakness in patients’ safety”.

“With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks can reduce the risk for such errors.”

Valentin, A. et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. The British Medical Journal, 2009;338:b814.