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
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Franklin et al's rapid response to Valentin et al's paper shows
unhappiness with the low error estimation at 7%. They quote self-
reportings only pick up "1 in 100 prescribing errors and 1 in 1000
administration errors". Are they suggesting the true incidence of errors
is between 700% and 7000%?
Of course the estimates will be wrong. All such estimates are wrong
and...it doesn't matter. We don't need to know the incidence to know we
have to do something to decrease it. A gardener watching greenfly attack
his roses doesn't need to calculate the percentage of roses which will be
affected before he takes steps to prevent it. And don't say we need
baseline figures (hey, why not use Franklin's quoted 18-173% as a precise
starting point?).
You still don't believe me. Read the conclusion to Valentin's paper, the
result of all of their efforts. Put any figure instead of the percentage
they measured (other than zero) and the conclusion would be written in
exactly the same way.
JL
Competing interests:
None declared
Competing interests: No competing interests
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
We read with great interest the multinational study by Valentin et
al[1], which assessed the frequency, characteristics and factors
contributing to parenteral drug administration errors in Intensive Care
Units (ICUs). The authors acknowledge that, due to under-reporting,
underestimation of the true error frequency is a limitation of the
incident self reporting method, which was used in their study.
Direct observation is considered the most efficient and accurate
method for detecting medication errors[2] and has been used for medication
error detection in five ICU studies[3-7]. Wrong dose was observed and
included among the three more frequent error types in all five direct
observation studies, while administration time and dose omission errors
were observed in four and three of these studies respectively, and were
included among the three more frequent error types in only two of these
five studies. In contrast, the study by Valentin et al[1], which was based
on error self-reporting found that the frequency of “wrong dose” errors
was much lower compared to the frequency of administration time errors and
dose omission errors. Could the discrepancy between the findings of the
Valentin study1 and those of the five direct observation studies[3-7] be
attributed to under-reporting of “wrong dose” medication errors?
We believe that there are at least two plausible reasons why
different types of medication error may not be equally reported when self
reporting is used: First, staff must become aware of an error in order to
report it and, compared to administration time and dose omission errors,
which can be detected through reviewing of ICU daily charts, dose errors
are much less likely to be noticed. Second, well-described bias of self
reporting include social desirability bias and self-esteem bias; according
to them, respondents tend to reply in a manner either viewed favorably by
important others or being consistent with their self-esteem perceptions
respectively[8]. Wrong dose has been primarily attributed to individual
deficiencies (especially of nurses), such as inadequate mathematical
skills or medication knowledge, limited experience and failure to follow
policies (i.e. properly checking drugs)[9]. In contrast, administration
time and dose omission errors have generally been associated with
organizational deficiencies, mainly increased workload (which was also
identified as a factor contributing to errors in the study by Valentin et
al[1]). Due to the subconscious tendency of being socially agreeable and
protecting self-esteem, it seems reasonable to expect that self reporting
individuals would more likely under-report types of medication error which
have been associated with personal deficiencies.
Although findings derived from multicenter studies are highly
generalizable, the importance of data collection bias should not be
overlooked. The hypothesis that “wrong dose” errors are under-reported
when error detection is based on self-report can be tested by studies
designed specifically for comparing the frequency of different error types
detected by direct observation vs. self reporting. Underestimation of dose
errors, if real and confirmed by additional studies, could have important
ramifications, because it would lead to erroneous conclusions about
medication error epidemiology and contributing factors, and could
therefore become the basis for ill-conceived, ineffective preventive
interventions.
References
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. Flynn EA, 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;59:436-46.
3. Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Tavakoli
Ardakani M. Errors in preparation and administration if intravenous
medications in the intensive care unit of a teaching hospital: an
observational study. Aust Crit Care 2008;21:110-6.
4. Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G.
Medication errors and adverse drug events in an intensive care unit:
direct observation approach for detection. Crit Care Med 2006;34:415-25.
5. Tissot E, Cornette C, Demoly P, Jacquet M, Barale F, Capellier G.
Medication errors at the administration stage in an intensive care unit.
Intensive Care Med 1999;25:353-9.
6. Van den Bemt PM, Fijn R, van der Voort PHJ, Gossen AA, Egberts
TCG, Brouwers JRBJ. Frequency and determinants of drug administration
errors in the intensive care unit. Crit Care Med 2002;30:846-50.
7. Calabrese AD, Erstad BL, Brandl K, Barletta JF, Kane SL, Sherman
DS. Medication administration errors in adult patients in the ICU.
Intensive Care Med 2001;27:1592-8.
8. Waltz CF, Strickland OL, Lenz ER. Measurement in Nursing and
Health Research: Third Edition. New York, NY: Springer Publishing Company,
Inc, 2005.
9. O’Shea E. Factors contributing to medication errors: a literature
review. J Clin Nurs 1999;8:496-504.
Competing interests:
None declared
Competing interests: No competing interests
It is doctors who have often asked me to make a connection between
two tubes which need joining, yet which have no dedicated connector. It
happens not infrequently.
Health care workers seem to reject help. The inferior metal Luer
predates current plastics technology by the best part of a century, yet is
still proudly advertised by sphygmomanometer makers as a selling point for
their manual devices used in indirect measurement of blood pressure. It is
doctors and nurses who want the older inferior technology - they are the
uninformed consumer driving the market.
Competing interests:
None declared
Competing interests: No competing interests
We commend the authors on their important work. Medication errors are
a clearly both a common and potentially preventable cause of patient
injury and death.
The authors’ conclusions that error reporting systems and routine
checks must be introduced in order to reduce risk are correct, however,
this alone is insufficient. The evidence for this is obvious insofar as,
these checks and reporting systems are already in place, yet the errors
continue to occur.
It is imperative that where possible we prevent the occurrence of
these errors. In some situations this can be achieved through engineered
solutions. Where wrong route errors are implicated, engineered solutions
are already available which prevent the possibility of these occurring.
The main issue with many of the wrong route errors is the ubiquitous
nature of the luer connector on medical devices.
We would like to highlight an example of an engineered solution
already in place in our hospital which prevents the unintentional
administration of local anaesthetic intended for epidural delivery into
intravenous cannulae. This is a tragic and common occurrence that has
already been raised by the National Patient Safety Agency[1] and exposed
by the press[2].
By providing clinicians with a modification of the current epidural
infusion systems wrong route drug errors, either of drugs intended for
epidural use being given intravenously, or, of intravenous drugs being
delivered to the epidural space are prevented. The system is modified such
that the local anaesthetic bag is irreversibly bonded to an infusion
system which is then continuous with the epidural filter and only has a
connector for attachment to an epidural catheter. There is no cross-
compatibility of these two systems and therefore no potential for error.
Similar engineered solutions have been successfully introduced for other
medical applications[3] and other solutions are being developed[4,5].
As the paper highlights, errors of drug administration are
multifactorial. Engineered solutions will provide an important adjunct to
prevent some of these errors. Wherever possible, preventing the
possibility of errors is the desirable solution.
References
1. National Patient Safety Agency Patient Safety Alert NPSA/2007/21
2. Mayra Cabrera 'unlawfully killed' by epidural blunder in hospital
The Times accessed on 13th March 2009
http://www.timesonline.co.uk/tol/life_and_style/health/article3314183.ece
3. Evans LA, Young PJ. Preventing iatrogenic air embolism in the
intensive care unit. Med Device Technol. 2007;18(3):36-7
4. Ramai Santhirapala, Ajay Arora, Joseph J. Carter, Peter J. Young.
A Non Interchangeable Connector System (NICS) for Central Venous Catheters
(Abstract) Critical Care Medicine December 2008 supplement
5. Joseph J. Carter, Ajay Arora, Ramai Santhirapala, Peter J. Young.
Safer Arterial Access: Preventing Accidental Arterial Injection
(Abstract). Critical Care Medicine December 2008 supplement
Competing interests:
None declared
Competing interests: No competing interests
Automatic identification and GS1 standards can reduce risk of medical errors
I was interested to note the conclusions of this report that
parenteral medication errors at the administration stage are common and a
serious safety problem in intensive care units.
I fully support the observation that 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.
The GS1 System of standards, recommended by DH, used in automatic
unique identification (such as bar coding) is just such a system. It has
been shown in “Coding for Success” (DH Feb 2007) that dispensing and
administration errors are significantly reduced by AIDC (Automatic
Identification and Data Capture).
GS1 standards are currently being ratified by NHS ISB and over 200
hospitals in England have now joined up for GS1 UK membership since the
NHS Connecting for Health programme on AIDC began 2 years ago. This has
enabled better control of medicines manufacturing, repackaging and over-
labelling procedures in hospitals and facilitated tracing systems for
surgical instrument decontamination. Working with the NPSA the GS1 System
is now also being used to enable automatic positive patient identification
at the bedside.
Competing interests:
None declared
Competing interests: No competing interests