Effects of the implementation of a preventive interventions program on the reduction of medication errors in critically ill adult patients

Journal of Critical Care

Volumn 28, Issue 4, 2013, Pages 451-460

  Romero, Carlos M ^a   Salazar, Nicole ^a,b   Rojas, Lorena ^b   Escobar, Leslie ^b   Griñén, Héctor ^b   Berasaín, María Angélica ^a   Tobar, Eduardo ^a   Jirón, Marcela ^b  

^a HOSPITAL CLÍNICO UNIVERSIDAD DE CHILE   (Chile)

^b UNIVERSITY OF CHILE   (Chile)

Author keywords

ICU; Medication errors; Multidisciplinary team; Pharmacist; Quality; Safety

Indexed keywords

AGENTS AFFECTING METABOLISM; ANTIINFECTIVE AGENT; CARDIOVASCULAR AGENT; CENTRAL NERVOUS SYSTEM AGENTS; HEMATOLOGIC AGENT; HORMONE; RESPIRATORY TRACT AGENT;

ADULT; ARTICLE; CONTROLLED STUDY; CRITICALLY ILL PATIENT; FEMALE; HUMAN; INTENSIVE CARE UNIT; INTERDISCIPLINARY COMMUNICATION; MAJOR CLINICAL STUDY; MALE; MEDICATION ERROR; MIDDLE AGED; OBSERVATIONAL STUDY; PRESCRIPTION; PREVALENCE; PREVENTIVE INTERVENTIONS PROGRAM; PREVENTIVE MEDICINE; PROSPECTIVE STUDY; SYSTEMIC THERAPY; CHI SQUARE DISTRIBUTION; CRITICAL ILLNESS; ICU; IN SERVICE TRAINING; MULTIDISCIPLINARY TEAM; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PATIENT SAFETY; PHARMACIST; QUALITY; SAFETY; STATISTICS;

ICU; MEDICATION ERRORS; MULTIDISCIPLINARY TEAM; PHARMACIST; QUALITY; SAFETY;

CHI-SQUARE DISTRIBUTION; CRITICAL ILLNESS; FEMALE; HUMANS; INSERVICE TRAINING; INTENSIVE CARE UNITS; MALE; MEDICATION ERRORS; MIDDLE AGED; PATIENT CARE TEAM; PATIENT SAFETY; PREVALENCE; PROSPECTIVE STUDIES;

EID: 84886714137     PISSN: 08839441     EISSN: 15578615     Source Type: Journal    
DOI: 10.1016/j.jcrc.2012.11.011     Document Type: Article

References (49)

1. Rothschild J.M., Landrigan C.P., Cronin J.W., et al. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005, 33:1694-1700.
2. Lesar T., Briceland I., Stein D. Factors related to errors in medication prescribing. JAMA 1997, 277:312-313.
3. Camiré E., Moyen E., Stelfox H.T. Medication errors in critical care: risk factors, prevention and disclosure. CMAJ 2009, 180:936-943.
4. Herout P., Erstad B. Medication errors involving continuously infused medications in a surgical intensive care unit. Crit Care Med 2004, 32:428-432.
5. Cullen D., Sweitzer B., Bates D., et al. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997, 25:1289-1297.
6. Ridley S., Booth S., Thompson C. Intensive Care Society's Working Group on Adverse Incident. Prescription errors in UK critical care units. Anaesthesia 2004, 59:1193-1200.
7. Valentin A., Capuzzo M., Guidet B., et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 2009, 338:b814.
8. Kane-Gill S., Weber R. Principles and practices of medication safety in the ICU. Crit Care Clin 2006, 22:273-290.
9. Kohn I.T. The Institute of Medicine report on medical error: overview and implications for pharmacy. Am J Health Syst Pharm 2001, 58:63-66.
10. van den Bemt P.M., Egberts T.C., de Jong-van den Berg L.T., Brouwers J.R. Drug-related problems in hospitalised patients. Drug Saf 2000, 22:321-333.
11. Costa L.A., Loureiro S., de Oliveira M.G.G. Errores de medicación de dos hospitales de Brasil. Farm Hosp 2006, 30:235-239.
12. Graciano M., Borges M., Dean B., et al. Concomitant prescribing and dispensing errors at Brazilian hospital: descriptive study. Clinics 2011, 66:1691-1697.
13. de Bartoli Cassiani S., Silvia Monzani A., Bauer de Camargo Silva A., et al. Identificación y análisis de los errores de medicación en seis hospitales brasileños. Cienc Enferm 2010, XVI:85-95.
14. Lavalle-Villalobos A., Payro-Cheng T., Martínez-Cervantes K., et al. El error médico en la prescripción de medicamentos y el impacto de una intervención educativa. Bol Med Hosp Infant Mex 2007, 64:83-90.
15. Gutierrez S., Mogni A., Berón A., et al. Errores de medicación en niños hospitalizados. Arch Pediatr Urug 2011, 82:133-140.
16. Salamano M., Palchik V., Botta C., et al. Patient safety: use of quality management to prevent medication errors in the hospital medication use cycle. Rev Calid Asist 2012, doi:10.1016/j.cali.2012.05.004.
17. Breeding J., et al. Medication Error Minimization Scheme (MEMS) in an adult tertiary Intensive Care Unit (ICU) 2009-2011. Aust Crit Care 2012, doi:10.1016/j.aucc.2012.07.003.
18. Flynn E.A., Baker K.N., Pepper D.W., et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002, 59:436-446.
19. Ferner R.E., Aronson J.K. Clarification of terminology in Medication Errors: definitions and classification. Drug Saf 2006, 29:1011-1022.
20. Leape L.L. Preventing adverse drug events. Am J Health Syst Pharm 1995, 52:379-382.
21. National Coordinating Council for Medication Error Reporting and Prevention NCCMERP Index for categorizing medication errors 2001, Accessed January 2009. http://www.nccmerp.org/pdf/taxo2001-07-31.pdf.
22. Barker K.N., McConnell W.E. The problem of detecting medication errors in hospitals. Am J Hosp Pharm 1962, 19:360-369.
23. Kopp B.J., Erstad B.L., Allen M.E., et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med 2006, 34:415-425.
24. Brod M., Tesler L.E., Christensen T.L. Qualitative research and content validity: developing best practices based on science and experience. Qual Life Res 2009, 18:1263-1278.
25. ATC classification index Structure and Principles. WHO Collaborating Centre for Drug Statistics Methodology 2001, Accessed on September 2012. http://www.whocc.no/atc/structure_and_principles.
26. Hussain E., Kao E. Medication safety and transfusion errors in the ICU and beyond. Crit Care Clin 2005, 21:91-110.
27. Jirón M. Pharmacy-Nursing shared vision for safe medication use in hospitals: Executive Session Survey. Am J Health Syst Pharm 2003, 60:1046-1052.
28. van den Bemt P.M., Fijin R., van der Voort P.H., et al. Frequency and determinants of drug administration errors in the intensive care unit. Crit Care Med 2002, 30:846-850.
29. Calabrese A., Erstad B., Brandl K., et al. Medication administration errors in adult patients in the ICU. Intensive Care Med 2001, 27:1592-1598.
30. Moyen E., Camiré E., Stelfox H.T. Clinical review: medication errors in critical care. Crit Care 2008, 12:208.
31. Kiekkas P., Karga M., Lemonidou C., et al. Medication errors in critically ill adults: a review of direct observation evidence. Am J Crit Care 2011, 20:36-44.
32. Curtis J.R., Cook D.J., Wall R.J., et al. Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team. Crit Care Med 2006, 34:211-218.
33. Kim M.M., Barnato A.E., Angus D.C., et al. The effect of multidisciplinary care teams on intensive care unit mortality. Ann Intern Med 2010, 170:369-376.
34. Netzer G., Liu X., Shanholtz C., Harris A., et al. Decreased mortality resulting from a multicomponent intervention in a tertiary care medical intensive care unit. Crit Care Med 2011, 39:284-293.
35. Rhodes A., Moreno R.P., Azoulay E., et al. Prospectively defined to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM). Intensive Care Med 2012, 38:598-605.
36. Bertsche T., Mayer I., Stahl R., et al. Prevention of intravenous drug incompatibilities in an intensive care unit. Am J Health Syst Pharm 2008, 65:1834-1840.
37. Grindrod K., Patel P., Martin J. What interventions should pharmacists employ to impact health practitioners' prescribing practices?. Ann Pharmacother 2006, 40:1546-1557.
38. Kane S.L., Weber R.J., Dasta J.F. The impact of critical care pharmacists on enhancing patient outcomes. Intensive Care Med 2003, 29:691-698.
39. Kopp B.J., Erstad B.L., Duby J.J. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J Heath Syst Pharm 2007, 64:483-487.
40. MacLaren R., Bond C.A., Marin S.J., Fike D. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. Crit Care Med 2008, 36:3185-3189.
41. Klopotowska J., Kuiper R., van Kan H., et al. On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study. Crit Care 2010, 14:R174.
42. Colpaert K., Claus B., Somers A., et al. Impact of computerized physician order entry on medications prescription errors in the intensive care unit: a controlled cross-sectional trial. Crit Care 2006, 10:R21-R29.
43. Wolfstadt J.I., Gurwitz J.H., Field T.S., et al. The effect computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review. J Gen Intern Med 2008, 23:451-458.
44. Poon E.G., Keohane C.A., Yoon C.S., et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med 2010, 362:1698-1707.
45. Institute of Medicine Report: health IT and patient safety: building safer systems for better care. The National Academies Available at:, Accessed 9 November, 2011. http://www.iom.edu.
46. Tissot E., Cornette C., Demoly P., et al. Medication errors at the administration stage in an intensive care unit. Intensive Care Med 1999, 25:353-359.
47. Martinez-Anton A., Sanchez J.I., Casanueva L. Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. Intensive Care Med 2012, 38:1532-1538.
48. Schneider P.J. Opportunities for pharmacy. Am J Health Syst Pharm 2007, 64(Suppl. 9):S10-S16.
49. Leape L.L., Cullen D.J., Clapp M.D., et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999, 282:267-270.