Intended for healthcare professionals

Rapid response to:

Research

Errors in administration of parenteral drugs in intensive care units: multinational prospective study

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b814 (Published 13 March 2009) Cite this as: BMJ 2009;338:b814

Rapid Response:

Error rates reported are likely to be an underestimate of the true incidence of errors

We note with interest this extensive study on errors in
administration of parenteral drugs in intensive care units (1). However,
we would recommend caution in interpreting the findings of this study. The
error rates reported are likely to be an underestimate of the true
incidence of errors. This is for two reasons. First, errors were
identified using self-reporting by hospital staff. Studies suggest that
only about 1 in 100 prescribing errors (2) and 1 in 1000 administration
errors (3) are reported using established incident reporting systems.
While the approach used in this study, encouraging staff to report all
errors identified during a very short, focussed period, is likely to have
resulted in higher reporting rates, the error rates identified are still
likely to be a significant under-estimate of the true error rates. The
error rate in the present study, calculated as percentage of all doses
given, is 7%. This is substantially lower than the parenteral medication
error rates of 18%-173% found in other studies in the ICU setting and
other wards using the “gold standard” method in this field, observation
of actual administration using independent observers (4-6). Second, the
authors only assessed five specific types of error. Other potentially
common administration errors associated with parenteral medication
including the use of the wrong diluent, incompatibility errors and wrong
administration rate errors, appear to have been excluded. Conducting
regression analyses based on a potentially small sub-set of reported
errors is therefore likely to be flawed.

We were also surprised that no information was presented about the
role of pharmacists in the units studied. It is routine practice to
include a pharmacist as part of the critical care team in many of the
countries included in the study. It has been shown that pharmacist
involvement reduces adverse events due to prescribing errors in the
critical care setting (7) and having a pharmacist involved with the multi-
disciplinary team is likely to also be associated with reduced
administration errors.

We would advocate the method of using independent observers
collecting data on actual practice (5;8;9) to understand the true
incidence and causes of administration errors in this setting.
Furthermore, to identify the true impact of interventions such as
electronic prescribing or the provision of parenteral medication by the
pharmacy department, completely different approaches, such as controlled
studies, are needed.

Bryony Dean Franklin
Professor of Medication Safety and Director, Centre for Medication and
Service Quality, Imperial College Healthcare NHS Trust / The School of
Pharmacy, University of London

Katja Taxis
Assistant Professor of Pharmacotherapy and Clinical Pharmacy, Department
of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care,
University of Groningen, The Netherlands

Nick Barber
Professor of the Practice of Pharmacy, The School of Pharmacy, University
of London

Reference List

(1) Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P et
al. Errors in administration of parenteral drugs in intensive care units:
multinational prospective study. BMJ 2009; 338:b814.

(2) Franklin BD, Vincent C, Schachter M, Barber N. Prescribing errors
- an overview of research methods. Drug Saf 2005; 28(10):891-900.

(3) Allan Flynn E, Barker KN, Pepper GA, Bates DW, Mikeal RL.
Comparison of methods for detecting medication errors in 36 hospitals and
skilled nursing facilities. Am J Health-Syst Pharm 2002; 59:436-446.

(4) Han PY, Coombes ID, Green B. Factors predictive of intravenous
fluid administration errors in Australian surgical care wards. Qual Saf
Health Care 2005; 14(3):179-184.

(5) Taxis K, Barber N. Ethnographic study of incidence and severity
of intravenous drug errors. BMJ 2003; 326:684-687.

(6) O'Hare MCB, Gallagher T, Shields MD. Errors in the administration
of intravenous drugs. BMJ 1995; 310:1536-1537.

(7) Leape LL, Cullen DJ, Dempsay Clapp M, Burdick E, Demonaco HJ,
Ives Erickson J et al. Pharmacist participation on physician rounds and
adverse drug events in the intensive care unit. JAMA 1999; 282(3):267-270.

(8) Franklin BD, O'Grady K, Donyai P, Jacklin A, Barber N. The impact
of a closed-loop electronic prescribing and administration system on
prescribing errors, administration errors and staff time: a before-and-
after study. Qual Saf Health Care 2007; 16(4):279-284.

(9) Dean B, Barber N. Validity and reliability of observational
methods for studying medication administration errors. Am J Health-Syst
Pharm 2001; 58:54-59.

Competing interests:
None declared

Competing interests: No competing interests

27 March 2009
K Taxis
Assistant Professor of Pharmacotherapy and Pharmaceutical Care
Bryony D. Franklin and Nick Barber
9713BV Groningen