An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

Thomas, Alain; Taylor, Robert Joseph

doi:10.1111/anae.12670

Cited by 23 publications

(28 citation statements)

References 24 publications

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“…With respect to the medication pathway, most incidents were associated with prescribing (53 incidents) and administration of medications (178 incidents). The observations were similar to those described in our more detailed review of medication incidents reported from the NW dataset , and support the concept of focusing on high‐risk medications . The 65% of medication incidents that we classified as ‘could have been avoided’ was also in keeping with our previous review .…”

Section: Resultssupporting

confidence: 85%

“…The observations were similar to those described in our more detailed review of medication incidents reported from the NW dataset , and support the concept of focusing on high‐risk medications . The 65% of medication incidents that we classified as ‘could have been avoided’ was also in keeping with our previous review . Enteral feed was more commonly associated with harm in this national review, largely due to the 24 described episodes of accidental intrapulmonary administration.…”

Section: Resultssupporting

confidence: 85%

“…We have previously found wide variations between units in the rate of reporting of different incidents in our reviews of the North West dataset . Unfortunately, to maintain confidentiality, we have been unable to explore if such variation exists nationally, or between different regions.…”

Section: Discussionmentioning

confidence: 93%

“…With respect to medication incidents, this review highlights the importance of high‐risk medications and processes of checking medications, which we have previously described in more detail . Intra‐pulmonary administration of enteral feed has been described as a ‘Never Event’, and guidance to prevent this was issued by the NPSA in 2011 .…”

Section: Discussionmentioning

confidence: 99%

“…The incidents held in this dataset had been classified using the same classification structure that has been used in this review. We have previously described summary data from this dataset for incidents submitted between 2009 and 2010 , and we have also reported thematic reviews of patient safety incidents from this data set .…”

Section: Methodsmentioning

confidence: 99%

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A review of patient safety incidents reported as ‘severe’ or ‘death’ from critical care units in England and Wales between 2004 and 2014

Thomas

Macdonald

2016

Anaesthesia

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SummaryWe analysed 1743 patient safety incidents reported between 2004 and 2014 from critical care units in England and Wales where the harm had been classified as 'severe' (1346, 77%) or 'death' (397, 23%). We classified 593 (34%) of these incidents as resulting in temporary harm, and 782 (45%) as more than temporary harm, of which 389 (22%) may have contributed to the patient's death. We found no described harm in 368 (21%) incidents. We classified 1555 (89%) of the incidents as being avoidable or potentially avoidable. There were changes over time for some incident types (pressure sores:

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Section: Resultssupporting

confidence: 85%

Section: Resultssupporting

confidence: 85%

Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 3 more Smart Citations

A review of patient safety incidents reported as ‘severe’ or ‘death’ from critical care units in England and Wales between 2004 and 2014

Thomas

Macdonald

2016

Anaesthesia

Self Cite

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Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands

et al. 2020

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Background Medication errors occur frequently in intensive care units (ICU). Voluntarily reported medication errors form an easily available source of information. Objective This study aimed to characterize prescribing, monitoring and medication transfer errors that were voluntarily reported in the ICU, in order to reveal medication safety issues. Setting This retrospective data analysis study included reports of medication errors from eleven Dutch ICU's from January 2016 to December 2017. Method We used data extractions from the incident reporting systems of the participating ICU's. The reports were transferred into one database and categorized into type of error, cause, medication (groups), and patient harm. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories. Based on the analysis, ICU medication safety issues were revealed. Main outcome measure The main outcome measure was the proportion of prescribing, monitoring and medication transfer error reports. Results Prescribing errors were reported most frequently (n = 233, 33%), followed by medication transfer errors (n = 85, 12%) and monitoring errors (n = 27, 4%). Other findings were: medication transfer errors frequently caused serious harm, especially the omission of home medication involving the central nervous system and proton pump inhibitors; omissions and dosing errors occurred most frequently; protocol problems caused a quarter of the medication errors; and medications needing blood level monitoring (e.g. tacrolimus, vancomycin, heparin and insulin) were frequently involved. Conclusion This analysis of voluntarily reported prescribing, monitoring and medication transfer errors warrants several improvement measures in these processes, which may help to increase medication safety in the ICU.

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A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children’s Intensive Care

et al. 2021

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Background Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas. Objective This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs). Methods We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents. Results In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols. Conclusions Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.

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An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

Cited by 23 publications

References 24 publications

A review of patient safety incidents reported as ‘severe’ or ‘death’ from critical care units in England and Wales between 2004 and 2014

A review of patient safety incidents reported as ‘severe’ or ‘death’ from critical care units in England and Wales between 2004 and 2014

Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands

A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children’s Intensive Care

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