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Related Experiment Videos

Does critical incident reporting contribute to medication error prevention?

Bernhard Frey1, Vera Buettiker, Maja I Hug

  • 1Department of Intensive Care and Neonatology, University Children's Hospital, Steinwiesstrasse 75, 8032 Zürich, Switzerland. Bernhard.Frey@kispi.unizh.ch

European Journal of Pediatrics
|November 9, 2002
PubMed
Summary

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Low-threshold monitoring of medication-related critical incidents (CIs) drives quality improvement. Even minor CIs, often detected late, led to essential system changes, highlighting the value of comprehensive drug safety surveillance.

Area of Science:

  • Patient Safety
  • Medication Safety
  • Quality Improvement in Healthcare

Background:

  • Medication-related critical incidents (CIs) are harmful or potentially harmful events.
  • CI monitoring aims to improve healthcare quality through systemic changes.
  • A voluntary, anonymous, non-punitive reporting system was utilized.

Purpose of the Study:

  • To analyze drug-related CIs in a neonatal-paediatric intensive care unit (ICU).
  • To emphasize the contribution of CIs to system changes for quality improvement.
  • To evaluate the impact of CI monitoring on patient safety.

Main Methods:

  • Prospective survey of drug-related CIs over one year (2001).
  • Data collected via voluntary, anonymous, non-punitive CI reporting.

Related Experiment Videos

  • CI severity graded as minor, moderate, or major; potentially life-threatening events identified.

    • Main Results:

    • 284 drug-related CIs were recorded; 76% were minor, 19% moderate, and 5% major.
    • 27% of CIs were intercepted before patient administration (17% before preparation, 10% before administration).
    • 46 CIs resulted in system changes, with 63% originating from minor incidents.

    Conclusions:

    • System changes were predominantly based on minor critical incidents, often detected after a delay.
    • This underscores the value of a "low-threshold" critical incident monitoring system.
    • Repeated checks during the drug delivery process are crucial for reducing adverse drug events.