Medication transfer, monitoring and prescribing errors in ICUs
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Medication transfer, monitoring and prescribing errors in ICUs Several medication safety issues which warrant improvement measures in intensive care units (ICUs) were detected by a study in the Netherlands, according to study results reported in the International Journal of Clinical Pharmacy. The study extracted data from the voluntary incident reporting systems (IRS) of 11 ICUs in 2016–2017. There were 701 reports, or 2–6 reports per bed per ICU. Removal of medication administration errors led to 345 reports for analysis (49%), comprising prescribing errors (PE; n=233, most frequently wrong dosages and omissions), medication transfer errors (MTE; n=84, many due to communication problems) and monitoring errors (MoE; n=27). ICUs with pharmacist attendance or a medication reconciliation services had higher report rates and percentages of PE and MTE, respectively. Serious harm from medication errors was associated with MTE (n=11), PE (n=5) and MoE (n=4). The most frequent error type was omissions during the ICU admission process (n=9), followed by monitoring problems (n=5) and wrong dose (n=4). The most frequently involved medication class was anti-infectives (n=64), followed by antithrombotic agents (n=58) and nervous system agents (n=57). Vancomycin was associated with 11 reports, mostly related to problems with therapeutic drug monitoring (TDM). Low molecule weight heparins (MNWHs) were associated with wrong dose errors (n=11) and omission errors (n=10), but also with duplicate medication errors (n=7). Omission of home nervous system medication was associated with harms including inadequate pain regulation or agitation. Other associations leading to harms included hypoglycaemia due to erroneous continuation of insulin, gastrointestinal bleeding after omission of proton pump inhibitors, and TDM errors with tacrolimus. The primary causes of error were related to problems with protocols in 90 cases, especially protocol or guideline not followed (n=67). There were 83 errors made while using computerised provider order entry (CPOE) systems. The authors note that PE "can be prevented by introducing or improving medication safety practices, like decision support software in the CPOE and the attendance of an ICU pharmacist". They add that "since it is known that MTE can be prevented by medication reconciliation, we emphasize that medication reconciliation at ICU admission, with an early restart of relevant home medication, should be part of ICU standard care". Bosma BE, et al. Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands. International Journal of Clinical 803499790 Pharmacy : 19 Aug 2020. Available from: URL: http://doi.org/10.1007/s11096-020-01101-5
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