[Medication errors on intensive care units: don't underestimate the risks due to transcription]

INTRODUCTION; Medication errors [ME] can harm patients and increase costs. ME are frequent in the intensive care units (ICU], where patients are critically ill and therefore more vulnerable. Publications about ME in the critical care setting are rare. The differences between settings, the lack of standardized definitions and the use of different methods do not allow transposing published results to a specific ICU. The goal of this observational study is to analyse our local situation in relation to the literature findings and determine improvement opportunities.

Rates of actual medication error [AME] and potential medication error [PME] per line of drug, and per patient-day. Distribution of errors among eight types considered clinically significant.

Intensive care unit, in a tertiary care hospital.

Error detection was based on the comparison between the prescriptions, the scheduling of the administrations [PME] and the actual medication administrations [AME).

229 lines with an AME were detected in 4636 lines of drugs administered to 144 patients during 373 patient-days. AME rate per line of drug was 5%. PME rate per line of drug was 17%. AME rate per patient-day was 61%. Dose omissions and not discontinued administrations accounted altogether for more than 50% of the total of AME.

The literature does not consider the transcription stage as a priority target for error reduction, but this work shows that, depending on the context, transcriptions can significantly increase opportunities for errors. As transcription does not add any value, its suppression seems therefore to be an interesting target for medication safety improvement.