Description of studies that presented errors as a percentage of observed medication preparations and numbers of drug administrations with errors
| Reference | Type of ICU | Method of study | Description of methods | Preparation and administration error definition | Percentage of observations with errors (wrong time errors excluded) |
| 26 | SICU, MICU, mixed ICUs | Observation of medication preparation and administration | Pharmacists at all by one involved institutions did the observation. All observers used the same definitions and collected data on a standardised form. Intravenous and oral medications were included and only regularly scheduled medications were monitored. Data collection occurred twice daily, once in the morning and once in the afternoon on every patient in the ICU. Errors were sorted based on type and patient outcome. Nurses were not aware of the observation. | Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer | 2.8 (1% of errors resulted in temporary harm) |
| 25 | MICU | Observation of medication preparation and 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 | 7 (no patient harm is mentioned in study) |
| 27 | NICU, PICU | Observation of medication preparation and administration | Pharmacy resident performed 18–12 h shifts, half day and half night. The nursing staff did not know the purpose of the observation. The observer recorded each medication dose, dosage form, frequency and route of administration, and other pertinent information on the monitoring form. Intravenous fluids and prn medications were not included in the study, but intravenous infusions were. The medications were recorded as prepared and administered correctly or incorrectly. When the drugs involved were capable of causing potential serious effects, the errors were classified as ‘serious.’ | Unauthorised dose, omitted dose, wrong dose, wrong route of admin, wrong rate of administration, wrong preparation of a dose, wrong dosage form, wrong time of administration (>±30 min from scheduled time) | 8.8 (no patient harm mentioned in study) |
| 28 | Not specified | Observation of medication preparation and administration | Administration errors were detected by using the disguised observation technique; nurses were unaware of the purpose of the study. A pharmacist followed nurses preparing and administering drugs in both hospitals on five consecutive days from 07:00 to 22:00. All observations were noted on data-collection forms and were compared with actual medication orders afterwards. Observations were also compared with general nursing protocols. Errors were categorised by type and severity. | Any error in the preparation and administration of drugs by nurses, that is, a deviation from written, printed or verbal medication orders; a deviation from drug information sheets provided by the manufacturer or from the information in a handbook on injectable drugs; or deviation from general nursing procedures used in the hospital. | 33.9 (no patient harm mentioned in study) |
ICU, intensive care unit; Prn medication, medications as needed.