Systematic evaluation of errors occurring during the preparation of intravenous medication

Parshuram, Christopher S.; To, Teresa; Seto, Winnie; Trope, Angela; Koren, Gideon; Laupacis, Andreas

doi:10.1503/cmaj.061743

Cited by 118 publications

(93 citation statements)

References 35 publications

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“…Adapa et al 11 reported that preparing infusions at the bedside in this emergent simulation resulted in an odds ratio of 17.0 (95% CI, 5.2-55) for making a medication error compared with preparing the infusions in a calmer environment or having the infusions prepared in the pharmacy. Other evidence [12][13][14][15] has highlighted the error-prone nature of preparing critical infusions at the bedside, including vasopressors and opioids. Task analysis 16 has identified a total of 41 potential steps in the process of preparing a drug infusion, providing 41 opportunities for error during the fast-paced environment of medical emergencies.…”

Section: Simulationmentioning

confidence: 99%

Medication Errors in Cardiopulmonary Arrest and Code-Related Situations

Flannery

Parli

2016

American Journal of Critical Care

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) was searched to identify relevant published studies on the overall frequency, types, and examples of medication errors during medical emergencies involving cardiopulmonary resuscitation and related situations, and the breakdown by type of error. The overall frequency of medication errors during medical emergencies, specifically situations related to resuscitation, is highly variable. Medication errors during such emergencies, particularly cardiopulmonary resuscitation and surrounding events, are not well characterized in the literature but may be more frequent than previously thought. Depending on whether research methods included database mining, simulation, or prospective observation of clinical practice, reported occurrence of medication errors during cardiopulmonary resuscitation and surrounding events has ranged from less than 1% to 50%. Because of the chaos of the resuscitation environment, errors in prescribing, dosing, preparing, labeling, and administering drugs are prone to occur. System-based strategies, such as infusion pump policies and code cart management, as well as personal strategies exist to minimize medication errors during emergency situations.

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Section: Simulationmentioning

confidence: 99%

Medication Errors in Cardiopulmonary Arrest and Code-Related Situations

Flannery

Parli

2016

American Journal of Critical Care

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“…• Medication reconciliation † (resulted in 1 medication order being changed for every 2.5 patients admitted) 21 • Satellite pharmacy 72,73 • Support for dose adjustments for patients with renal or liver failure*…”

Section: Pharmacistsmentioning

confidence: 99%

Medication errors in critical care: risk factors, prevention and disclosure

Camiré

Moyen²,

Stelfox³

2009

Canadian Medical Association Journal

153

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Key points• Medication reconciliation may improve patient safety in the intensive care unit, and an updated list of medications should be maintained, including long-standing medications, the reasons for starting new medications and their planned stop dates and the reasons for discontinuing or holding old medications.• Engaging pharmacists in inpatient rounds in the intensive care unit may decrease the risk of adverse drug events.

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“…A Canadian study involving the preparation of infusions found that 34.7% of prepared infusions had concentration errors. 40 Another study evaluating i.v. preparation and administration errors demonstrated a rate of 13-84% in the United Kingdom, Germany, and France.…”

Section: IV Medicationsmentioning

confidence: 99%