Medication errors and adverse drug events in an intensive care unit: Direct observation approach for detection

Abstract

Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.

Errores de medicación en el Servicio de Medicina de un hospital de alta complejidad

“…Resultados similares han sido reportados por otros autores en trabajos realizados en unidades de mayor complejidad, aunque fueron obtenidos a través de reportes voluntarios, revisión de fichas clínicas y/o entrevista de los profesionales 13,16 , los cuales tienden a subestimar la ocurrencia de EM 4,23,31,32 . La observación directa ha demostrado ser la más exhaustiva y precisa como método de detección de EM 4,23,31,32 .…”

“…En el estudio sólo se incluyeron los EM raíz, es decir, aquellos que originaron el problema, aunque posteriormente causaran errores en otras etapas 23 . No obstante, en un paciente podía ocurrir más de un EM raíz.…”

Methods for Assessing the Preventability of Adverse Drug Events

“…Thus, inter-rater reliabilities ranged from poor to excellent (kappa 0.19-0.98; overall agreement 26-97%). Of the 24 (17%) articles that reported excellent reliability of the preventability assessment (kappa >0.81), one study used an explicit algorithm in the fourth group (36) and 23 used more implicit methods (8,9,22,(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56). In four (3%) articles, reliability assessments were mentioned, but as no exact figures for the reliability of the preventability assessment were presented, the articles are not presented in Table IV (24,57,58).…”

Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice

“…[14][15][16][17][18][19] Nevertheless, data on the rates of adverse events and medical errors in ICUs are contradictory because nosocomial infections and iatrogenic complications due to invasive procedures or medications are not always preventable. 14,17,18 In addition, adverse events are often responsible for patients' being transferred to the ICU, further complicating the analysis of preventability of accidental injuries in ICUs. 19 Therefore, the rates of preventable adverse events per 1000 ICU patient-days are estimated to be between 13 and 40, and in-ICU medical errors could prolong the ICU stay by 15% and increase hospital costs by 10%.…”