Injected Medication Errors a Major Problem
THURSDAY March 12, 2009 -- Mistakes involving injected medications are a major safety problem in intensive care units, a new study reveals.
Researchers monitored errors in 1,328 patients in 113 ICUs in 27 countries over a 24-hour period in January 2007. Two U.S. sites with 50 patients were included in the study.
Dr. Andreas Valentin of the Rudolfstiftung Hospital in Vienna, Austria, and colleagues identified 861 injected medication errors involving 441 patients. No errors occurred in 67 percent of patients, while 250 patients (19 percent) experienced one error, and 191 patients (14 percent) experienced more than one error.
Errors caused no harm in the majority (71 percent) of patients, but 15 errors did cause permanent harm or death in 12 patients (0.9 percent). Medical trainees were involved in eight of those 15 errors.
The most common causes of errors were: wrong time of administration (386); missed medication (259); wrong dose (118); wrong drug (61); and wrong route (37).
ICU staff listed workload/stress/fatigue as a contributing factor in 32 percent of errors. Other contributing factors included: a recently changed drug name (18 percent); written communication problems (14 percent); oral communication problems (10 percent), and violation of standard protocol (9 percent).
The risk of an injected medication error increased significantly with a higher level of patient illness, a higher level of care, and a higher rate of drug injections. The risk was lower when a critical incident reporting system was in place and when there was an established routine of checks at nurses' shift changes, the researchers said.
They said their findings show that administration of injected medications is a weak point in patient safety in ICUs. But that risk can be reduced through organizational plans such as error reporting systems and routine checks at shift changes.
The study will be published online March 13 in the BMJ.
The U.S. Agency for Healthcare Research and Quality outlines five steps to safer health care.
Posted: March 2009
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