Prescription errors in UK critical care units

Area of Science:

• Medical Safety
• Clinical Pharmacy
• Critical Care Medicine

Background:

• Drug prescription errors are a significant cause of adverse events in healthcare.
• The national incidence of prescription errors in UK critical care settings was previously unknown.
• Understanding error rates is crucial for developing targeted prevention strategies.

Purpose of the Study:

• To determine the incidence and variation of drug prescription errors in UK critical care units.
• To classify the types and severity of prescription errors observed.
• To identify common error categories and high-risk medications.

Main Methods:

• A prospective study conducted across 24 UK critical care units over a 4-week period.
• Daily recording of new and re-written prescriptions.
• Classification of errors based on nature and severity, including adherence to British National Formulary (BNF) guidelines.

Main Results:

• A total of 21,589 new prescriptions were analyzed, with 15% containing one or more errors (145.5 errors per 1000 new prescriptions).
• Potassium chloride, heparin, magnesium sulphate, paracetamol, and propofol were the most frequently involved medications in errors.
• Of the 3141 errors identified, 19.6% were classified as significant, serious, or potentially life-threatening.

Conclusions:

• Prescription error rates in critical care appear higher than in other hospital areas, though serious error rates are comparable to other high-risk practices.
• Common errors included non-adherence to BNF, ambiguous orders, non-standard nomenclature, and illegible writing.
• Further research and interventions are needed to reduce prescription errors and improve patient safety in critical care.