Errors in medication administration
2
Accepted: 18 January 1999 B. Dean Centre for Pharmacy Practice, The School of Pharmacy, Brunswick Square, University of London, London WC1N 1AX, UK e-mail: [email protected] Tel. + 44 (171) 7 53 59 40 Fax + 44 (1 71) 7 53 59 20 People generally undergo medical treatment in the hope that it will benefit their health. However, there is increasing awareness among health care professionals and the general public that patients may instead be harmed as a result of errors in medication use. It has been estimated that 1–2 % of patients admitted to hospi- tals in the United States are harmed as a result of medi- cation errors [1], and that each error that results in harm costs an additional US $5000, excluding legal costs [2]. Such estimates, however, are usually based on studies in general medical or general surgical populations; criti- cally ill patients, who may be more vulnerable to the ef- fects of medication errors, are often ignored. The re- search described on page 353, in which Tissot et al. stud- ied medication errors in an intensive care unit (ICU), is therefore particularly important. There are two main types of medication error: pre- scribing errors and medication administration errors. Tissot et al.’s study focuses on medication administra- tion errors (MAEs), which are usually defined as dis- crepancies between the medication prescribed and the medication administered, and explores their incidence and potential clinical significance in a French ICU. The authors used an observation-based method to identify MAEs. This involves a researcher observing nurses pre- paring and administering medication, recording details of all doses given, and then comparing the observations to the original medication orders in order to identify any discrepancies. It is generally accepted that this is the only way to measure MAE rates; alternatives such as self-reporting have been shown grossly to underesti- mate the numbers of errors that occur. Until recently, there has been only one observation-based MAE study in an ICU; this took place more than ten years ago in a paediatric ICU in Canada [3]. There has been only one more recent study; this was a relatively small study in a paediatric ICU in Switzerland [4]. There have been no studies in adult ICUs and no larger studies in Europe, where systems of drug preparation and administration are very different from those in the United States and Canada. Tissot et al.’s study therefore fills several gaps in the literature. Tissot et al. observed 2009 acts of medication prepa- ration and administration, where one dose of medica- tion could be associated with more than one act, and identified 132 MAEs (6.6 %). The most common types of MAE were incorrect dilution of intravenous medica- tion, administration of the wrong dose, wrong rate of ad- ministration and administration of incompatible drugs via the same intravenous line. Many different causes are proposed for these MAEs; these include lack of knowledge, illegible or incomplete medication orders, lack of standardisation and errors in the transcription of medication orders. It is also suggested that the in- volvement of a pharmacist in the ICU may have pre- vented many of the MAEs. In the United Kingdom, the introduction of ward pharmacy in the 1960 s was shown to reduce MAEs significantly [5]; perhaps such an evaluation should now be repeated in a European ICU. One methodological issue that the present authors had to tackle was the denominator with which to ex- press the incidence of MAEs. In the first observation- based study of MAEs, Barker and McConnell [6] de- cided that the denominator should be the total oppor- tunities for error, defined as all doses ordered plus any unordered doses given. Since that time, most other authors have also used this method. A potential prob- B. Dean Errors in medication administration Intensive Care Med (1999) 25: 341–342 Ó Springer-Verlag 1999 EDITORIAL
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Transcript of Errors in medication administration
Accepted: 18 January 1999
B. DeanCentre for Pharmacy Practice, The School of Pharmacy, BrunswickSquare, University of London, London WC1N 1AX, UKe-mail: [email protected]. + 44 (171) 753 5940Fax + 44 (1 71) 7535920
People generally undergo medical treatment in thehope that it will benefit their health. However, there isincreasing awareness among health care professionalsand the general public that patients may instead beharmed as a result of errors in medication use. It hasbeen estimated that 1±2 % of patients admitted to hospi-tals in the United States are harmed as a result of medi-cation errors [1], and that each error that results in harmcosts an additional US $5000, excluding legal costs [2].Such estimates, however, are usually based on studiesin general medical or general surgical populations; criti-cally ill patients, who may be more vulnerable to the ef-fects of medication errors, are often ignored. The re-search described on page 353, in which Tissot et al. stud-ied medication errors in an intensive care unit (ICU), istherefore particularly important.
There are two main types of medication error: pre-scribing errors and medication administration errors.Tissot et al.'s study focuses on medication administra-tion errors (MAEs), which are usually defined as dis-crepancies between the medication prescribed and themedication administered, and explores their incidenceand potential clinical significance in a French ICU. Theauthors used an observation-based method to identifyMAEs. This involves a researcher observing nurses pre-paring and administering medication, recording detailsof all doses given, and then comparing the observationsto the original medication orders in order to identifyany discrepancies. It is generally accepted that this is
the only way to measure MAE rates; alternatives suchas self-reporting have been shown grossly to underesti-mate the numbers of errors that occur. Until recently,there has been only one observation-based MAE studyin an ICU; this took place more than ten years ago in apaediatric ICU in Canada [3]. There has been only onemore recent study; this was a relatively small study in apaediatric ICU in Switzerland [4]. There have been nostudies in adult ICUs and no larger studies in Europe,where systems of drug preparation and administrationare very different from those in the United States andCanada. Tissot et al.'s study therefore fills several gapsin the literature.
Tissot et al. observed 2009 acts of medication prepa-ration and administration, where one dose of medica-tion could be associated with more than one act, andidentified 132 MAEs (6.6%). The most common typesof MAE were incorrect dilution of intravenous medica-tion, administration of the wrong dose, wrong rate of ad-ministration and administration of incompatible drugsvia the same intravenous line. Many different causesare proposed for these MAEs; these include lack ofknowledge, illegible or incomplete medication orders,lack of standardisation and errors in the transcriptionof medication orders. It is also suggested that the in-volvement of a pharmacist in the ICU may have pre-vented many of the MAEs. In the United Kingdom,the introduction of ward pharmacy in the 1960 s wasshown to reduce MAEs significantly [5]; perhaps suchan evaluation should now be repeated in a EuropeanICU.
One methodological issue that the present authorshad to tackle was the denominator with which to ex-press the incidence of MAEs. In the first observation-based study of MAEs, Barker and McConnell [6] de-cided that the denominator should be the total oppor-tunities for error, defined as all doses ordered plusany unordered doses given. Since that time, most otherauthors have also used this method. A potential prob-
B. Dean Errors in medication administration
Intensive Care Med (1999) 25: 341±342Ó Springer-Verlag 1999 EDITORIAL
lem with this approach, however, is that it assumes thateach dose of medication can be associated with onlyone MAE. While this may be a reasonable assumptionfor oral doses, it is somewhat tenuous for intravenousmedication that may require several stages of prepara-tion and administration. Tissot et al. therefore devel-oped an alternative approach, calculating separate er-ror rates for each stage of the preparation and admin-istration process. While this represents a more practi-cal approach to the study of MAEs associated with in-travenous medication, it does mean that the results ofthe present study cannot easily be compared withthose of previous studies. A potential solution to thisproblem may be to calculate error rates per patientday, these could then be used together with assess-ments of error severity to indicate the risks to whichindividual patients are exposed. The other problem as-sociated with comparing results of different studies isthat there can be wide differences in the error catego-ries and definitions used. Previous studies have beencriticised for not considering the severity of the errorsthat occur; Tissot et al. asked a physician to assess thepotential severity of the errors identified. While thisapproach was not assessed in terms of validity or reli-ability, it definitely represents a step in the right direc-tion.
Another problem associated with studying MAEs inintravenous medication is that of identifying and defin-ing physicochemical incompatibilities. There is a pauci-ty of information available on the physicochemical com-patibility of drugs; in one study in an adult ICU it wasfound that there was no information available for nearlyhalf of the drug combinations used [7]. In the presentstudy, where no information was available for a givencombination it was assumed that the drugs were com-patible. While in many cases this was undoubtedly thecase, in others the drugs may have been chemically orphysically incompatible and the true incidence of in-compatibilities may therefore be higher than the au-thors suggest.
The authors are to be commended for carrying out astudy that fills several gaps in the current literature.Their study indicates that ICUs are not error free, andsuggests that many of the errors that occur are likely tohave adverse effects on the patient. Errors are rarelythe fault of individuals and it is important that individu-als are not inappropriately blamed or punished for theiroccurrence. Instead, as health care professionals weshould work together to prevent them. It is thereforehoped that the present study is followed by furtherwork to identify ways of reducing MAEs in the criticalcare environment.
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References
1. Barber ND, Dean BS (1998) The inci-dence of medication errors and ways toreduce them. Clin Risk 4: 103±106
2. Bates DW, Spell N, Cullen DJ et al.(1997) The costs of adverse drug eventsin hospitalized patients. JAMA 277:307±311
3. Tisdale JE (1986) Justifying a pediatriccritical±care satellite pharmacy by medi-cation-error reporting. Am J HospPharm 43: 368±371
4. Schneider M-P, Cotting J, Pannatier A(1998) Evaluation of nurses' errors asso-ciated in the preparation and administra-tion of medication in a pediatric inten-sive care unit. Pharm World Sci 20:178±182
5. Hill PA, Wigmore HM (1967) Measure-ment and control of drug-administrationincidents. Lancet I:671±674
6. Barker KN, McConnell WE (1962) Theproblems of detecting medication errorsin hospitals. Am J Hosp Pharm 19:360±369
7. Dean BS, Poolman R (1996) Are incom-patibilities a problem? A study into theadministration of multiple drug infusionsin an ICU. Pharm in Practice 6: 371±372
