Medication Error

OVERVIEW

• 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

PREDISPOSING FACTORS

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

MANAGEMENT

General

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

Prescribing

• 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

Administration

• 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

• 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

• 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

Storage

• 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)

PREVENTION

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