List the factors predisposing to medication error in ICU. How can these be minimised?
Answer and interpretation
Note to examiners: This is a very broad question. The following is an example of a good answer to this question. It is expected that there will be a range of different answers by candidates. No breakdown has been provided for the marks. Examiners are urged to use their discretion and should award marks to all reasonable answers.
- Severity of illness
- Extremes of age
- Prolonged hospitalisation
- Sedation, patient unable to tell nurse medication wrong.
- Types of medications are infusions or weight based or programmed if an infusion pump is required.
- Number of medications, more than on the ward
- Number of interventions therefore increased risk of complications.
- Complex environment – high stress, high turnover, high nursing turnover.
- Emergency admission
- Multiple care providers
Minimisation of medication errors
Optimise medication process
- Medication standardisation
- Computerised physician order entry
- Barcode technology
- Computerised infusion device
- Medication reconciliation
Eliminate situational factors
- Avoid excessive consecutive and cumulative working hours
- Minimise interrupts and distractions
- Trainee supervision and graduated responsibility
Oversight and error interception
- Primary doctor in charge of all drugs ( intensivist)
- Adequate staffing
- Pharmacist participation
- Quality assurance as part of education program. ( Evidence of adverse drug events dropping by 66% with pharmacist involvement, results in reducing length of stay, decreasing mortality and medication expenditure)
- If increased patient/ nurse ratio, increasing error.
- Mention AIMS ICU (Australian incident monitoring study in Intensive Care) has been developed with goal of balancing strengths with limitations of error reporting.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.