Reference | Type of ICU | Method of study | Definition of ME | MEs/1000 patient-days | |
1 | 2 MICU, 3 SICU | Multifaceted | Nurses and pharmacists were asked to report incidents using logs, a trained nurse visited each unit at least twice daily on weekdays and solicited information from staff concerning all actual or potential drug-related incidents, and a study nurse briefly reviewed all charts at least daily on weekdays | Preventable and potential ADEs | 18.6 |
8 | 2 CSICU, 2 CS stepdown unit | Multifaceted | Pump-related transaction data were obtained from smart pump log downloads. Log reports included pump alerts. In addition, error reports were collected by chart review, solicited staff reports, hospital incident reports and a computerised ADE surveillance monitor. | Errors during ordering, transcribing, dispensing, administering or monitoring. These errors have the capacity to cause injury and reach the patient. | 22.1 |
12 | MICU, CCU | Multifaceted | Primary method of data collection was direct continuous observation. Voluntary and solicited reports were also used to identify incidents. Computerised ADE detection was also used to monitor events. Also, guided chart abstraction by trained research nurses was performed. | ME in ordering or execution of treatment, inadequate monitoring system or medication related failure to take precautions or follow protocol to prevent accidental injury | 129.5 |
16 | MICU, CCU | Multifaceted | A team of two nurse chart reviewers and six physician observers collected data on errors made by interns, which was supplemented by voluntary reports and a computerised event-detection monitor | An ME that causes harm, or has the potential to cause harm, related to the ordering or administration of pharmaceutical agents, blood products or intravenous fluids | 146.1 |
17 | NICU, PICU | Voluntary reporting | Written incident reports were submitted by persons who noticed the errors. All incident reports are reviewed anonymously by a pharmacy manager and possible corrective measures are discussed in monthly quality assurance meetings. The non-punitive nature of the review is emphasised, and ICU personnel are encouraged to send reports even when errors seem trivial. Patient injuries are classified on a 1–4 severity scale. | A dose of medication that deviates from the physicians' order as written in the medical record. Except for errors of omission, the medication dose must actually reach the patient to be considered an error. | 8.8 |
18 | Mixed ICU | Voluntary reporting | An incident registration form was developed without any patient ID except for sex and age. The person reporting was allowed to remain anonymous but the professional status was requested. The seriousness of the errors was evaluated by four ICU staff members. Prior to starting the reporting process, staff were informed of incident reporting during meetings and with the internal newsletter. They were asked to report errors no matter how small. | All events when treatment or observation differed from a planned one, and when this was not a part of the natural course of the disease | 11.4 |
19 | NICU | Voluntary reporting | Errors were identified using critical incident forms. The forms were analysed monthly by a multidisciplinary risk management group and graded according to severity. Non-punitive system. | Not provided | 14.7 |
20 | MICU | Voluntary reporting | A locally developed, card-based reporting programme available to hospital physicians and staff. The SAFE card solicited core info about patient safety events and could be anonymous if desired. The intervention involved encouraging the non-punitive nature of the programme and open communication about safety. | Not provided | 64 |
21 | 2 multidisciplinary ICUs | Voluntary reporting | The research team attempted to familiarise the staff with the concept of incident reporting, and to describe the non-punitive nature of the study. The incident reporting form requested the location, reporter's profession, type of unintended event, severity of unintended event and the time of day it was detected. | Event that reduce or could have reduced the safety margin for the patient while in the ICU. Specifically, prescription error, transcription error, wrong dose and wrong route of administration. | 90.9 |
22 | Paediatric cardiac ICU | Voluntary reporting | ME report forms were filled out and analysed. Info collected: profession of reporter, location of event, type of error (supply, administration, prescription), details of event, including clinical consequences. Anonymous. Non-punitive. | A mistake made at any stage of in the provision of a pharmaceutical product to a patient | 241 |
23 | ICU, PICU, NICU | Prescription review | Pharmacists reviewed prescriptions for therapy and prescription errors, and filled out a standardised form when they were found, which categorised their actions in response to the error, and the clinical significance of the error | Therapy errors- incorrect choice of drugs for a defined disease, incorrect drug because of similarity in name or interactions between drugs prescription errors –incorrect dosage, route, frequency, patient, or length of treatment | 8.2 (1.6=clinically significant errors) |
24 | Multidisciplinary ICU | Prescription review | A pharmacist reviewed the nursing MAR for the previous 24 h period and compared it with the physician's orders in the patients chart and recorded all doses on a patient data collection sheet. The patient's TISS score was available for the exact date/time of error, as were ICU deaths. | Drug administered to wrong patient, wrong dose, wrong medication, wrong route of administration, wrong time, patient has allergy to prescribed medication, omission of a medication, error in infusion rate, improper administration and administration of the wrong dosage form | 497.5 (no mistakes resulted in significant patient harm) |
7 | SICU | Prescription review | ICU pharmacist analysed every medication order of randomly selected patients during study period. An independent panel evaluated the severity of the events. | Medication prescribing errors: minor—no potential to cause harm intercepted—potential to cause harm but intercepted in time serious-non-intercepted potential ADEs (potential to cause harm) and ADEs (actually causes harm) | 2344 (all) 519 (serious) |
25 | MICU | Observation of medication administration | Pharmacy residents observed nurses' administration of medications. The nurses knew the purpose of the study. The length of observation was 5 h/day, during the heaviest period of medication preparation/administration. All observations were noted, then later compared with original physicians' orders, manufacturers' data and data available in the literature. Potential clinical significance was evaluated by an ICU physician. | Wrong drug preparation, dose error, wrong administration technique, physicochemical compatibility error | 1500 |
21 | 2 multidisciplinary ICUs | Observation of entire medication process | Two medical residents acted as observers. They filled out standard form during morning shifts for 14 days. The form requested the location, reporter's profession, type of unintended event, severity of unintended event and the time of day it was detected. The staff were unaware of the observation. | Event that reduce or could have reduced the safety margin for the patient while in the ICU. Specifically: problems with medications: prescription error, transcription error, wrong dose, wrong route of administration | 78 |
ADE, adverse drug event; ICU, intensive care unit; MAR, Medication Administration Record; SAFE, Safety, Actions, Focus Everyone; TISS, Therapeutic Intervention Scoring System.