List  the  factors  predisposing  to  medication  error  in  ICU.  How  can  these  be minimised?

[Click here to toggle visibility of the answers]

College Answer

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.

Factors predisposing

Patient factors 
•    Severity of illness
•    Extremes of age
•    Prolonged hospitalisation
•    Sedation, patient unable to tell nurse medication wrong.

Medication errors 
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.

ICU environment 
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)

Nursing/Patient ratio 
•    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.

Discussion

LITFL have an excellent condensed synopsis of this topic. It draws upon large-scale review articles such as this one and this one.

The author of the college answer felt that the question was broad and general. However, one should note that the question asks for risk factors and the strategies for minimising them.

First, I will focus on answering the question:

Risk Factors for Medication Error
And the Various Means of Managing Them

Risk factor

Management strategy

Illness severity

  • Increase awareness of this as a risk factor through education
  • Increase the involvement of pharmacy staff with the most severely ill patients

Extremes of age

  • Increase awareness of this as a risk factor through education
  • Rationalise geriatric polypharmacy
  • Increase the involvement of geriatric medicine in the management of these patients

Unexpected admission

  • Procolise routine medication administration guidelines to make it available out of hours
  • Ensure the availability of pharmacy staff out of hours
  • Ensure protection from interruptions for staff who are responsible for preparing and administering medications

Prolonged hospital stay

  • Increase awareness of this as a risk factor through education
  • Ensure regular reviews of the medication list by qualified pharmacists

Doses of drugs which require dosage calculations

  • Computerise dose calculations (and integrate them into CIS prescription systems)
  • Ensure protocols for medication are widely circulated and easy to follow
  • Mandatory doublechecking of all dose calculations by a second nurse
  • Introduce electronic infusion pumps with built-in dose calculation firmware
  • Weigh the patients regularly, to have accurate anthropometric measurements for dose calculations.

Multiple medications

  • Structure medication delivery in a systematic manner
  • Ensure protection from interruptions for staff who are responsible for preparing and administering medications

Sedation and decreased participation of the patient

  • Engage the family to provide pharmacy staff with existing medication lists, allowing for improved medication reconciliation
  • Contact primary healthcare providers to get an up-to-date medication history and list of known or suspected allergies

High staff stress, poor nurse-to-patient ratios

  • Ensure the protection of 1:1 staffing for patients who are at risk of medication error
  • Maintain the availability of "floating" nursing staff to assist with preparation of medications, checking of calclations and administration of the drugs

Multiple simultaneous care providers

  • Provide a clear and well-structured schedule of medication administration
  • Maintain a plan of

"Broadly" speaking, a candidate with unlimited time resources would produce an answer resembling the one below

Significance of medication error

  • ICU patients have ~ 1.7 medical errors per day
  • Of these, ~ 78% are medication errors
  • Of these, ~ 54% are errors of medication administration
  • Of medication errors in ICU, ~ 20% are lifethreatening, and ~50% lead to the escalation of the level of support.

Risk factors for medication error:

Table 2 from this article has a more detailed breakdown.

  • Illness severity
  • Extremes of age
  • Unexpected admission
  • Sedation
  • Prolonged hospital stay
  • Doses of drugs which require dosage calculations
  • High staff stress, poor nurse-to-patient ratios
  • Multiple simultaneous care providers

Prevention of medication error

  • Standardise the medications
  • Medication reconciliation (reconciling the list of ICU medications with the normal list of medications which the patient takes at home)
  • Computerise dose calculation and infusion devices
  • Adequate staffing
  • Checklist for drug administration
  • Avoid excessive working hours
  • Pharmacist participation in ICU care

Management of a medication error

  • Full disclosure to the patient and their family
  • Documentation the medical record
  • Staff councelling and/or education
  • Audit of medication error events
  • Implementation of evidence-based preventative strategies

References

Moyen, Eric, Eric Camiré, and Henry Thomas Stelfox. "Clinical review: medication errors in critical care." Crit Care 12.2 (2008): 208.

 

Camiré, Eric, Eric Moyen, and Henry Thomas Stelfox. "Medication errors in critical care: risk factors, prevention and disclosure."  Canadian Medical Association Journal 180.9 (2009): 936-943.

 

Pronovost, Peter, et al. "Medication reconciliation: a practical tool to reduce the risk of medication errors." Journal of critical care 18.4 (2003): 201-205.