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Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection
Brian J Kopp1, Brian L Erstad, Michelle E Allen
1University Medical Center.
Objective:
To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence.
Design:
Prospective, direct observation study.
Setting:
Tertiary care academic medical center.
Patients:
Patients in a medical/surgical intensive care unit.
Interventions:
Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort.
Measurements And Main Results:
The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%).
Conclusions:
Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.
Insights
Direct observation revealed frequent medication errors and adverse drug events, with one preventable error for every five doses. Most errors, including omissions and wrong doses, were preventable, highlighting system vulnerabilities.
Area of Science:
- Pharmacovigilance
- Patient Safety Research
- Health Systems Analysis
Background:
- Medication errors and adverse drug events (ADEs) pose significant risks in healthcare settings.
- Previous studies often rely on indirect reporting methods, potentially underestimating error rates.
- Understanding system failures is crucial for implementing effective prevention strategies.
Purpose of the Study:
- To determine the incidence and preventability of medication errors and potential/actual ADEs.
- To evaluate system failures contributing to medication errors.
- To compare direct observation findings with traditional reporting methods.
Main Methods:
- A prospective, direct observation study was conducted in a tertiary care academic medical center.
- Patients in a medical/surgical intensive care unit were observed.
- Interventions were limited to errors posing substantial patient harm.
Main Results:
- One preventable error occurred for every five medication doses administered.
- 83% of clinically important medication errors led to potential ADEs, and 17% led to actual, preventable ADEs.
- Common errors included omissions, wrong doses, wrong drugs, incorrect administration techniques, and drug-drug interactions.
Conclusions:
- Direct observation reveals a higher incidence of preventable ADEs compared to chart reviews or incident reporting.
- The majority of potential and actual ADEs identified were deemed preventable.
- Systemic improvements are needed to address prescribing and administration errors to enhance patient safety.
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