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Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units
  1. Pascale Carayon1,2,
  2. Tosha B Wetterneck2,3,
  3. Randi Cartmill1,
  4. Mary Ann Blosky4,
  5. Roger Brown5,
  6. Robert Kim6,
  7. Sandeep Kukreja7,
  8. Mark Johnson1,3,
  9. Bonnie Paris8,
  10. Kenneth E Wood4,
  11. James Walker9
  1. 1Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, USA
  2. 2Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
  3. 3Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
  4. 4Geisinger Health System, Danville, Pennsylvania, USA
  5. 5Department of Research Design & Statistics, University of Wisconsin School of Nursing, Madison, Wisconsin, USA
  6. 6Oregon Pulmonary Associates, Portland, Oregon, USA
  7. 7Franciscan Saint Francis Health System, Greenwood, Indiana, USA
  8. 8Quality Quest for Health of Illinois, Peoria, Illinois, USA
  9. 9Siemens Healthcare, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Pascale Carayon, Department of Industrial and Systems Engineering, Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3126 Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53705, USA; carayon{at}engr.wisc.edu

Abstract

Objective To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process.

Methods Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process.

Results An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16–24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process.

Conclusions Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.

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