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National study on the distribution, causes, and consequences of voluntarily reported medication errors between the
Asad Latif1, Nishi Rawat, Aliaksei Pustavoitau
1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. alatif1@jhmi.edu
Objective:
To compare the distribution, causes, and consequences of medication errors in the ICU with those in non-ICU settings.
Design:
: A cross-sectional study of all hospital ICU and non-ICU medication errors reported to the MEDMARX system between 1999 and 2005. Adjusted odds ratios are presented.
Setting:
Hospitals participating in the MEDMARX reporting system.
Interventions:
None.
Measurements And Main Results:
MEDMARX is an anonymous, self-reported, confidential, deidentified, internet-accessible medication error reporting program that allows hospitals to report, track, and share medication error data. There were 839,553 errors reported from 537 hospitals. ICUs accounted for 55,767 (6.6%) errors, of which 2,045 (3.7%) were considered harmful. Non-ICUs accounted for 783,800 (93.4%) errors, of which 14,471 (1.9%) were harmful. Errors most often originated in the administration phase (ICU 44% vs. non-ICU 33%; odds ratio 1.63 [1.43-1.86]). The most common error type was omission (ICU 26% vs. non-ICU 28%; odds ratio 1.00 [0.91-1.10]). Among harmful errors, dispensing devices (ICU 14% vs. non-ICU 7.1%; odds ratio 2.09 [1.69-2.59]) and calculation mistakes (ICU 9.8% vs. non-ICU 5.3%; odds ratio 1.82 [1.48-2.24]) were more commonly identified to be the cause in the ICU compared to the non-ICU setting. ICU errors were more likely to be associated with any harm (odds ratio 1.89 [1.62-2.17]), permanent harm (odds ratio 2.45 [1.17-5.13]), harm requiring life-sustaining intervention (odds ratio 2.91 [1.86-4.56]), or death (odds ratio 2.48 [1.18-5.19]). When an error did occur, patients and their caregivers were rarely informed (ICU 1.5% vs. non-ICU 2.1%; odds ratio 0.63 [0.48-0.84]) by the time of reporting.
Conclusions:
More harmful errors are reported in ICU than non-ICU settings. Medication errors occur frequently in the administration phase in the ICU. When errors occur, patients and their caregivers are rarely informed. Consideration should be given to developing additional safeguards against ICU errors, particularly during drug administration, and eliminating barriers to error disclosures.
Insights
Medication errors in intensive care units (ICUs) are more harmful than those in other hospital settings. Development of safeguards and transparent reporting are crucial for patient safety.
Area of Science:
- Patient Safety
- Healthcare Quality Improvement
- Medication Error Analysis
Background:
- Medication errors pose a significant threat to patient safety across healthcare settings.
- Understanding the nuances of medication errors in intensive care units (ICUs) versus non-ICU environments is critical for targeted interventions.
Purpose of the Study:
- To compare the distribution, causes, and consequences of medication errors between ICU and non-ICU hospital settings.
- To identify specific factors contributing to medication errors in critical care environments.
Main Methods:
- A cross-sectional study analyzed over 800,000 medication errors reported to the MEDMARX system (1999-2005).
- Data included error origin, type, harm level, and reporting context (ICU vs. non-ICU).
- Adjusted odds ratios were calculated to compare error characteristics between settings.
Main Results:
- While non-ICUs reported more errors overall, ICUs had a higher proportion of harmful errors.
- Medication administration was the most frequent phase for errors in both settings, but more so in the ICU.
- Dispensing device issues and calculation errors were more common causes of harmful errors in the ICU.
- ICU errors were significantly more likely to result in permanent harm, require life-sustaining interventions, or lead to death.
- Patients and caregivers were rarely informed of errors in either setting.
Conclusions:
- Medication errors in ICUs, though less frequent overall, carry a higher risk of severe patient harm.
- Interventions should focus on improving medication administration processes and safeguards within ICUs.
- Addressing barriers to transparent error disclosure is essential for learning and preventing future incidents.
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