Safe prescribing and minimisation of medication error

By Alex Yartsev - 13/04/2017
Last updated 13/04/2017 - 18:52

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	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

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

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.

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