Errors in the administration of injected medication in intensive care units occur frequently, a study across 27 countries suggests.
Austrian researchers collected data on more than 1,300 patients, 200 of them in the UK, over a 24-hour period. Of the 441 patients affected, seven suffered permanent harm and five died partly because of the error, the British Medical Journal reported. Medical staff often cited stress and tiredness as contributing factors. Data was collected by researchers from Rudolfstiftung Hospital from a total of 113 intensive care units, of which 17 were in the UK. Nearly half of the affected patients suffered more than one mistake during the period covered. The most frequent errors were related to the wrong time of administration and missing doses altogether. Cases of incorrect doses and wrong drugs being given were also reported. A total of 69% of the errors occurred during routine care. Mistakes occurred with many types of drugs, including insulin for diabetics, sedatives and blood-clotting drugs. The doctors and nurses who took part in the study cited stress and tiredness as a contributing factor in a third of mistakes. Recent changes in the drug’s name, poor communication between staff and violation of protocols were also mentioned. The odds of an error being made increased significantly for the most severely ill patients. Researchers said this reflected the complexity of their care. ‘Worrying’ Lead researcher Dr Andreas Valentin said the problems identified applied to all the health systems involved in the study. He said just one in five units reported no adverse events during the 24-hour period studied. “It is a really serious problem. The administration of injected medication is a weak point in patient safety,” he said. “With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks at shift changes can reduce the risk of such errors.” A Patients Association spokesman said: “The findings are worrying. We know staff work really hard in intensive care units, but there are no excuses for errors. “Protocols must be followed and managers should be carrying audits to make sure they are.” ‘International problem’ In a statement, the Intensive Care Society said the aim must be to refine care to minimise drug errors. It said that critically ill patients often required complex care, with the use of many different drugs, some unusual, which were often administered using specialist equipment. “The urgency of treatment can also mean that these drugs have to be located rapidly, prepared efficiently and administered quickly to prevent further deterioration. “Unfortunately, this pressure does mean that the combined total incident rate is almost inevitably higher than in care areas where fewer medicines are required.” The society said many units had developed training programmes to increase patient safety, including measures to highlight and learn from “near misses”. Work was also under way to standardise concentrations of some drugs often given to critically ill patients, refine the use of antibiotics and minimise the risk of adverse drug reactions. The Department of Health said it was working closely with the National Patient Safety Agency (NPSA), professional organisations and pharmacists to reduce the incidence of medication errors, which it described as “clearly an international problem”.