Medication Error


  • Medication error occurs when a medication given inappropriately regardless of whether  an adverse clinical outcome occurs
  • drug error incidence = 1/135 anaesthesia
  • can cause significant harm to patients
  • need to recognise and adopt techniques to minimise such events


ICU factors

  • complex environment: high stress, high turnover, high nursing turnover
  • emergency admissions
  • multiple care providers
  • storage area
  • handovers and miscommunication when patients transferred from wards/inter-hospital

Medication factors

  • packaging: often many drugs have similar packaging (narcotics)
  • often infusions based on weight
  • patient on multiple infusions
  • drug interactions when on multiple drugs

Patient factors

  • severity of illness
  • time critical drug administration (e.g. during resuscitation)
  • extremes of age
  • prolonged hospitalisation
  • sedation, unable to comminicate
  • no access to prior history

Heathcare worker factors

  • inadequate training
  • stress
  • sleep deprivation
  • circadian dysynchrony
  • under the influence of mind altering substances
  • poor handwriting



  • aim is to give correct drug, to correct patient by correct route and record information accurately


  • prescriber must have adequate knowledge of pharmacology, including interactions and complications
  • take thorough drug history
  • write legibly
  • drugs administered by non-medical personnel should have medical supervision and a written order
  • good communication
  • access to information systems
  • computerised prescription systems
  • medication reconciliation


  • minimise distraction when drawing up
  • adequate light
  • bar code technology
  • avoid fatigue and cumulative working hours
  • minimise interruptions and distractions
  • adequate staffing
  • Pharmacist participation
  • quality assurance as a part of education program
  • optimise nurse to patient ratio
  • adequate training and supervision
  • AIMS ICU (Australasian Incident Monitoring Study in ICU)


  • purchasing and inventory should minimise drug error
  • avoidance of look-a-like packaging
  • changes to packaging must be widely communicated
  • stocking of different concentrations should be avoided
  • avoid need for dilution (pre-diluted)

Storage (workspace)

  • tidy
  • organised
  • standardised
  • emergency drug drawer
  • look-alike ampoules must be stored apart
  • store in original packaging prior to drawing up
  • appropriate trays


  • labels should have agreed and clear writing
  • pre-printed labels should be colour coded by drug class
  •  if labels not available use a permanent marker pen

Drawing up and checking drugs prior to Administration

  • read label (check name and dose)
  • regular checking for expired drugs
  • label syringes appropriately
  • draw up one drug at a time and label
  • if interrupted when drawing up a drug, then discard
  • before administering check drug and dose with a second person or an automated device
  • any one ampoule should be administered to only one patient


  • time interval from drawing up and administering should be short
  • store logically and orderly
  • drugs with different routes should not be stored together
  • emergency drugs should only be drawn up where there is time critical response -> otherwise can be given inadvertently.

Maintenance of Accurate Records

  • keep accurate records
  • keep ampoules so drugs can be reconciled if problem develops
  • discard ampoules once finished with

Infusion Drugs

  • infusion pumps and syringe drivers should be standardised
  • label patient end of the infusion
  • caution of one way valves to avoid siphoning of infused drug
  • always flush following drug administration to ensure drug is not still in line (e.g. neuromuscular blocker during anesthesia)


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
  • adequate staffing

Oversight and error interception

  • Primary doctor in charge of all drugs ( intensivist)
  • Adequate staffing and nurse:patient ratio
  • Pharmacist participation (adverse drug events dropping by 66% with pharmacist involvement, results in reducing length of stay, decreasing mortality and medication expenditure)
  • Quality assurance as part of education program
  • AIMS ICU (Australian incident monitoring study in Intensive Care) has been developed with goal of balancing strengths with limitations of error reporting

CCC 700 6

Critical Care


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.

| INTENSIVE | RAGE | Resuscitology | SMACC

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