Intensive Care Unit: Medication Errors

Problem Identification

A patient’s safety is a worldwide priority in preventing medication errors before they lead to permanent or temporary harm, financial loss, psychological trauma to patients and health care providers, and death. As stated by Aronson (2009), a medication error is characterized by the incorrect performance of prescriptions, negligence, under-reporting, or a lack of information – the factors that can cause complications of the underlying disease or even death. The mentioned mistakes are committed by doctors and other health care workers in the process of prescribing, preparing, dispensing, and administering medications (Hussain & Kao, 2015; Garrouste-Orgeas et al., 2012). As a result, medication errors can lead to the appearance of various diseases or aggravate the existing ones. In the US, such errors annually cost the health care system up to $ 177 billion depending on a certain care unit. In Intensive Care Unit (ICU) settings, there is insufficient time to react to patients’ changing symptoms, and little effort to make the hospital settings safer (Donaldson, 2008). The author also emphasizes the need to educate nurses instead of punishing them in case of medical errors since the policies currently introduced in ICUs cannot ensure patients’ safety, thus deteriorating their health conditions.

Specifying the problem of medication errors in ICUs, it is essential to pinpoint the situation with nurses who are expected to perform administration and monitoring while caring for patients. di Simone et al. (2016) argue that nurses lack pharmacological knowledge and skills and especially those regarding intravenous medications that affect their practices in drug preparation and administration. The multifaceted and ever-changing needs of patients cause the need for continuous education. The discussed issue is also considered by other scholars to reveal the role of nurse preparation in the context of ICUs and medication errors. As noted by di Muzio, Marzuillo, de Vito, La Torre, and Tartaglini (2016), there is a connection between positive attitudes and proper behaviors in nurses, which illustrates one of the predictors of a medication error. Consistent with the study by di Simone et al. (2016), the one by di Muzio et al. (2016) concludes that there is a need to initiate targeted nursing education in ICUs. Reviewing the above-mentioned articles along with the study conducted by Cho, Park, Choic, Hwang, and Bates (2014), one may suppose that the nature of a medication error contains several types such as prescription, preparation, administration, dispense, and documentation mistakes. The results of the research by the Centers for Disease Control and Prevention (2011) show that central line-associated bloodstream infections are often caused by a medication error in ICUs. Considering that the existing challenges are associated with the given health care problem, it seems critical to identify the causes and factors contributing to its existence.

Reasons for the Existence of the Problem

According to US Food and Drug Administration (FDA), approximately 7,000 patients in the US die every year due to errors in the use of medicines (Cho et al., 2014). Medication errors undermine the faith of patients in the health care system and raise the financial burden (Kunkel, Rosenqvist, & Westerling, 2007). The specified problem is determined by a large number of different factors and is comprehensive. In addition to attending physicians, it also concerns nurses, laboratory technicians, doctors of diagnostic departments, pharmacists, manufacturers of medicines, as well as patients and their caregivers.

Medication errors can be caused by the following reasons:

  • Patients get confused and take medication wrong.
  • Doctors prescribe an incorrect dosage or form of medication required for the treatment of a specific patient.
  • Due to incorrect reading of the prescribed medication, nurses give the wrong drug or an inadequate dose (Cohen, 2007).
  • Persons caring for a patient, due to incorrect reading of the label on the container with the drug, give him or her incorrect drug or the wrong dose.
  • A nurse or a patient himself or herself violates the rules for storing the drug, as a result of which the medication becomes less effective (MacFie, Baudouin, & Messer, 2015).

It should be noted that the similarity of denominations and packages of different medications is one of the frequent reasons for using the wrong drug. Such errors often result in deaths, and their cost is estimated at millions of dollars per year. According to Moyen, Camiré, and Stelfox (2008), in the United States, more than 25 percent of all medication errors are caused by confusion in similar names of drugs, and 33 percent of errors occur due to the use of an incorrect drug in connection with the similarity of packaging design. According to the above authors, 15-25 percent of erroneous prescriptions of medication are caused by the similarity of spelling or pronunciation of their names. Indeed, there are plenty of examples of similar names both among international non-proprietary names and among trade names of reference and reproduction drugs.

An inadequate thoroughness in gathering a patient’s anamnesis upon admission to the hospital, which results in incomplete information about constantly taken medications in the history of the illness, is responsible for at least 27 percent of medical errors in the subsequent selection of therapy (Moyen et al., 2008). The most frequent mistake in such cases is the abolition of the medication, which should be taken regularly. Approximately half of such errors are not detected until a patient has negative consequences. Incomplete reflection of all information in the medical history can lead to an interruption of the previously selected therapy, the appointment of incorrect treatment regimens, and also significantly hinders the detection of side effects.

In some cases, doctors make errors while prescribing medicines, especially in certain categories of patients. Older adults, pregnant women, and children are in this regard in a high-risk group since they often require specific drugs, dosages, or both in comparison with other patients (Kiekkas, Karga, Lemonidou, Aretha, & Karanikolas, 2011). The risk factors for a medication error consist of the age of a patient less than 15 years or older than 64 years and a large number of drugs assigned to him or her. Errors occur primarily in the treatment of diseases of the cardiovascular system, infectious diseases, musculoskeletal system diseases, eyes, and skin (Krahenbuhl-Melcher et al., 2007). Also, incorrect recommendations are often given to patients with malignant tumors and other diseases requiring immunosuppressive therapy. Some other types of errors may involve errors in drug interactions when one drug intensifies or weakens the effect of the other. Drug interactions are more likely to occur in people taking several medications simultaneously (Velo & Minuz, 2009). In order to minimize the risks of the above fashion, caregivers need to be aware of all the drugs that their patients take, including those prescribed by other health care workers and over-the-counter drugs. In their turn, patients should maintain and update a list of all medications they take with a dosage indication and carry this list for all visits to health care facilities or have them in case of admission to the ICU. If there is any doubt as to what medicines are being used, a patient may be asked to bring all of his or her medicines to the health facility.

Medical communication can also be predisposed to poor communication between health workers at different stages of medical care and the lack of adequate monitoring of nurses in many medical institutions. The factors of the working environment contain the workload of the staff, the time constraints that are assigned to a physician per patient, and the constant stress associated with this (Garrouste-Orgeas et al., 2010). To a greater extent, this item affects patients with co-morbid pathologies since time limit leaves insufficient period to evaluate the possibility of drug interaction or neglects the need to recalculate the doses of medication in the presence of a patient, let us say, with renal or hepatic insufficiency.

Interventions Suggested to Address Errors in ICUs

The World Health Organization (WHO) launched a global campaign aimed at reducing the number of errors associated with prescribing and using drugs, twice over the next five years. As part of the global initiative, WHO experts urge countries to develop and implement clear and well-established mechanisms in health care systems relating to the administration of drugs, their dosage, control of admission, monitoring and directly taking medications themselves. Particular attention should be paid to patients who take drugs with a high risk of harm when they are used improperly, and also several drugs to treat various diseases and conditions. In addition, it is necessary to provide patients with clear instructions on the use of medications and to inform about possible risks associated with improper intake of medications.

Quality improvement is another option suggested by several scholars. Donaldson (2008) focuses on the Institute of Medicine (IOM) recommendations regarding patient safety and assumes the four key areas of enhancement, including the establishment of a National Center for Patient Safety, the implementation of compulsory and voluntary reporting systems, the change in the roles of patients, experts, and accreditation groups, and the creation of a safety culture. At this point, the scholar suggests applying the principle of a user-centered design and work safety, avoiding reliance on vigilance, and anticipating unexpected events (Donaldson, 2008). By engaging patients in their care

The improvement of the system of training for staff working at all levels of medical care: doctors, nurses, and managers would benefit in addressing the problem. Donabedian (1990) claims that the enhanced communication between medical workers of different specialties and patients and their families at different stages of medical care can greatly improve this situation due to well-coordinated teamwork. Timely and complete provision of necessary information about possible adverse effects of medicinal preparations to medical workers is another option to consider (Bohomol, Ramos, & D’Innocenzo, 2009). The reviewed body of the research demonstrates the possibilities of modern technologies that provide doctors with quick access to appropriate instructions, computers for calculating doses depending on a patient’s age, body weight, kidney function, etc., as well as information on the most common and important adverse drug interactions.

One of the founders of the theory of quality in the sphere of public health, Donabedian (2005), described the quality and components for its achievement in the aspect of medical care. He proposed a well-known approach for assessing quality, identifying three categories: the structure (material and technical resources, human resources, organizational structure), the process (specific actions undertaken during the provision of medical care), and the outcome (the effect of providing medical assistance to the patient’s health condition and the society as a whole), the analysis of which can draw conclusions about the quality of medical care. In their article, Moore, Lavoie, Bourgeois, and Lapointe (2015) apply this model to access its effectiveness in trauma care. The relevance of the structure-process-outcome model was proved in the course of the quantitative study. However, to ensure the availability of medical care and improve the effectiveness of medical services that should meet the needs of the population and advanced medical science, it is not enough just to meet the requirements for the structure for the provision of medical care (El Haj, Lamrini, & Rais, 2013). It is necessary, more to the point, to build a competent system for managing the existing elements of the structure.

Elaborating on Donabedian’s model, Liu, Singer, Sun, and Camargo (2011) suggest the introduction of several initiatives to improve the quality of medical care:

  • to create an appropriate legislative and regulatory framework for the regulation of quality assurance mechanisms of the medical assistance;
  • to adjust the legal framework, the structures, and resources (personnel, a financial aspect, and information);
  • to establish appropriate technological standards for better results and more effectively monitor the performance of medical technologies.

It should also be emphasized that Donabedian (2003) singled out certain spheres ensuring the quality of care. The first area is medical specialist – supply- services. The scope includes the methods and technologies used, which depend on professional knowledge and skills. The second area refers to the conditions for providing medical assistance such as confidence, comfort, and confidentiality. The third sphere involves the contribution of a patient and his or her environment. The fourth area I associated with the provision of public assistance. The scope includes the following components: accessibility of assistance and the actions of medical specialists. Dalal, Barto, and Smith (2015) distinguish key internal and external factors affecting the quality management process. The internal components of the quality management system of medical care are factors that can be influenced within the medical organization to improve the efficiency of the system: leadership, the organization of the process, a patient contribution, employees, information and knowledge, and the use of resources.

The medical organization can influence the internal components mainly independently. There are several external components of the system management of the quality of care – factors that are highly dependent on the following conditions: society as a whole, partners, and financing (Kruer, Jarrell, & Latif, 2014). The external components are not influenced only by the medical organizations. Success in the work of the medical organization and patient satisfaction and safety in ICUs largely depend on the effectiveness of the established system of quality management of medical care. In this regard, the problem of medication errors in ICUs remains relevant and requires a change in policies and practices to enhance patient outcomes.

References

Aronson, J. (2009). Medication errors: Definitions and classifications. British Journal of Clinical Pharmacology, 67(6), 599-604.

Bohomol, E., Ramos, L. H., & D’Innocenzo, M. (2009). Medication errors in an intensive care unit. Journal of Advanced Nursing, 65(6), 1259-1267.

Centers for Disease Control and Prevention. (2011). Vital signs: Central line–associated blood stream infections—United States, 2001, 2008, and 2009. Annals of Emergency Medicine, 58(5), 447-450.

Cho, I., Park, H., Choic, Y., Hwang, M., & Bates, D. (2014). Understanding the nature of medication errors in an ICU with a computerized physician order entry system. PLoS One, 9(12). Web.

Cohen, M. (2007). Medication errors. Washington, DC: American Pharmacists Association.

Dalal, K., Barto, D., & Smith, T. (2015). Preventing medication errors in critical care. Nursing Critical Care, 10(5), 27-32.

di Muzio, M., Marzuillo, C., de Vito, C., La Torre, G., & Tartaglini, D. (2016). Knowledge, attitudes, behavior and training needs of ICU nurses on medication errors in the use of IV drugs: A pilot study. Signa Vitae, 11(1), 182-206.

di Simone, E., Tartaglini, D., Fiorini, S., Petriglieri, S., Plocco, C., & di Muzio, M. (2016). Medication errors in intensive care units: Nurses’ training needs. Emergency Nurse, 24(4), 24-29.

Donabedian, A. (1990). The seven pillars of quality. Archives of Pathology & Laboratory Medicine, 114(11), 1115-1118.

Donabedian, A. (2003). An introduction to quality assurance in health care. New York, NY: Oxford University Press.

Donabedian, A. (2005). Evaluating the quality of medical care. The Milbank Quarterly, 83(4), 691-729.

Donaldson, M. (2008). An overview of to err is human: Re-emphasizing the message of patient safety. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Chapter 3). Rockville, MD: Agency for Healthcare Research and Quality.

El Haj, H., Lamrini, M., & Rais, N. (2013). Quality of care between Donabedian model and ISO9001V2008. International Journal of Quality Research, 7(1), 17-30.

Garrouste-Orgeas, M., Philippart, F., Bruel, C., Max, A., Lau, N., & Misset, B. (2012). Overview of medical errors and adverse events. Annals of Intensive Care, 2(2), 1-9.

Garrouste-Orgeas, M., Timsit, J., Vesin, A., Schwebel, C., Arnodo, P., Lefrant, J. … Soufir, L. (2010). Selected medical errors in the intensive care unit. AJRCCM, 181(2), 1-17.

Hussain, E., & Kao, E. (2005). Medication safety and transfusion errors in the ICU and beyond. Critical Care Clinician, 21, 91-110.

Kiekkas, P., Karga, M., Lemonidou, C., Aretha, D., & Karanikolas, M. (2011). Medication errors in critically ill adults: A review of direct observation evidence. American Journal of Critical Care, 20(1), 36-44.

Krahenbuhl-Melcher, A., Schlienger, R., Lampert, M., Haschke, M., Drewe, J., & Krahenbuhl, S. (2007). Drug-related problems in hospitals: A review of the recent literature. Drug Safety, 30, 379-407.

Kruer, R. M., Jarrell, A. S., & Latif, A. (2014). Reducing medication errors in critical care: A multimodal approach. Clinical Pharmacology: Advances and Applications, 6, 117-126.

Kunkel, S., Rosenqvist, U., & Westerling, R. (2007). The structure of quality systems is important to the process and outcome, an empirical study of 386 hospital departments in Sweden. BMC Health Services Research, 7, 104-112.

Liu, S. W., Singer, S. J., Sun, B. C., & Camargo, C. A. (2011). A conceptual model for assessing quality of care for patients boarding in the emergency department: Structure-process-outcome. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 18(4), 430-435.

MacFie, C., Baudouin, S., & Messer, P. (2015). An integrative review of drug errors in critical care. SAGE Journals, 17(1), 63-72.

Moore, L., Lavoie, A., Bourgeois, G., & Lapointe, J. (2015). Donabedian’s structure-process-outcome quality of care model: Validation in an integrated trauma system. Journal of Trauma and Acute Care Surgery, 78(6), 1168-1175.

Moyen, E., Camiré, E., & Stelfox, H. T. (2008). Clinical review: Medication errors in critical care. Critical Care, 12(2), 208-218.

Velo, G. P., & Minuz, P. (2009). Medication errors: Prescribing faults and prescription errors. British Journal of Clinical Pharmacology, 67(6), 624-628.