Question 21 from the first paper of 2010 asks the candidate to list the factors predisposing to medication error in ICU, and how to manage them. LITFL have an excellent condensed synopsis of this topic. It draws upon large-scale review articles such as this one and this one.
Medication errors in the ICU
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.
Causes and predisposing factors
Risk Factors for Medication Error
And the Various Means of Managing Them
(Table 2 from this article has a more detailed breakdown)
Risk factor
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Management strategy
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Illness severity
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- Increase awareness of this as a risk factor through education
- Increase the involvement of pharmacy staff with the most severely ill patients
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Extremes of age
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- 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
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Unexpected admission
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- 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
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Prolonged hospital stay
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- Increase awareness of this as a risk factor through education
- Ensure regular reviews of the medication list by qualified pharmacists
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Doses of drugs which require dosage calculations
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- 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.
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Multiple medications
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- Structure medication delivery in a systematic manner
- Ensure protection from interruptions for staff who are responsible for preparing and administering medications
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Sedation and decreased participation of the patient
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- 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
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High staff stress, poor nurse-to-patient ratios
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- 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
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Multiple simultaneous care providers
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- Provide a clear and well-structured schedule of medication administration
- Maintain a plan of
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Prevention of medication error in brief summary
- 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