Intensive care errors frequent

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”.

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