Intended for healthcare professionals


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

BMJ 2009; 338 doi: (Published 13 March 2009) Cite this as: BMJ 2009;338:b814
  1. Andreas Valentin, associate professor1, director of intensive care unit 2,
  2. Maurizia Capuzzo, consultant in anaesthesia and intensive care medicine3,
  3. Bertrand Guidet, professor456,
  4. Rui Moreno, professor7,
  5. Barbara Metnitz, statistician8,
  6. Peter Bauer, professor and head of core unit of medical statistics and informatics8,
  7. Philipp Metnitz, professor9
  8. on behalf of the Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM) and the Sentinel Events Evaluation (SEE) Study Investigators
  1. 1Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
  2. 2Rudolfstiftung Hospital, Medical Department II, Juchgasse 25, A-1030 Vienna
  3. 3Department of Anaesthesia and Intensive Care, University Hospital of Ferrara, Ferrara, Italy
  4. 4INSERM, Unité de Recherche en Epidemiologié, Systemes d’Information, et Modelisation, Paris, France
  5. 5Faculty of Medicine, University Pierre et Marie Curie, Paris
  6. 6Assistance Publique, Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris
  7. 7Department of Intensive Care, Hospital de St António dos Capuchos, Centro Hospitalar de Lisboa (central, e.p.e), Lisbon, Portugal
  8. 8Section of Medical Statistics, Medical University of Vienna, Vienna
  9. 9Department of Anaesthesiology and General Intensive Care, Medical University of Vienna, Vienna
  1. Correspondence to: A Valentin andreas.valentin{at}
  • Accepted 5 December 2008


Objective To assess on a multinational level the frequency, characteristics, contributing factors, and preventive measures of administration errors in parenteral medication in intensive care units.

Design Observational, prospective, 24 hour cross sectional study with self reporting by staff.

Setting 113 intensive care units in 27 countries.

Participants 1328 adults in intensive care.

Main outcome measures Number of errors; impact of errors; distribution of error characteristics; distribution of contributing and preventive factors.

Results 861 errors affecting 441 patients were reported: 74.5 (95% confidence interval 69.5 to 79.4) events per 100 patient days. Three quarters of the errors were classified as errors of omission. Twelve patients (0.9% of the study population) experienced permanent harm or died because of medication errors at the administration stage. In a multiple logistic regression with patients as the unit of analysis, odds ratios for the occurrence of at least one parenteral medication error were raised for number of organ failures (odds ratio per increase of one organ failure: 1.19, 95% confidence interval 1.05 to 1.34); use of any intravenous medication (yes v no: 2.73, 1.39 to 5.36); number of parenteral administrations (per increase of one parenteral administration: 1.06, 1.04 to 1.08); typical interventions in patients in intensive care (yes v no: 1.50, 1.14 to 1.96); larger intensive care unit (per increase of one bed: 1.01, 1.00 to 1.02); number of patients per nurse (per increase of one patient: 1.30, 1.03 to 1.64); and occupancy rate (per 10% increase: 1.03, 1.00 to 1.05). Odds ratios for the occurrence of parenteral medication errors were decreased for presence of basic monitoring (yes v no: 0.19, 0.07 to 0.49); an existing critical incident reporting system (yes v no: 0.69, 0.53 to 0.90); an established routine of checks at nurses’ shift change (yes v no: 0.68, 0.52 to 0.90); and an increased ratio of patient turnover to the size of the unit (per increase of one patient: 0.73, 0.57 to 0.93).

Conclusions Parenteral medication errors at the administration stage are common and a serious safety problem in intensive care units. With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks can reduce the risk for such errors.


  • We thank Mary McKenney for editorial advice, Gerhard Krenn for programming the study website, and the staff of all the units that contributed to the study. A list of people in charge of the study at the unit level can be found at

  • Contributors: AV, MC, BG, RM, and PM contributed to the design of the study. AV and PM managed organisation and data collection. AV, BM, and PB analysed the data. BM and PB designed and carried out the statistical analysis. AV wrote the draft of the report and is guarantor. All authors contributed to the final writing of the report and approved the final version.

  • Funding: The SEE study was supported and funded by the Austrian Center for Documentation and Quality Assurance in Intensive Care Medicine (ASDI) and endorsed by the European Society of Intensive Care Medicine (ESICM).

  • Competing interests: None declared.

  • Ethical approval: Because the study was observational and no additional interventions were performed, the need for informed consent was waived by the institutional review board. Each unit, however, was made responsible for obtaining local permissions, as necessary, according to local regulations.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

View Full Text