Cent Eur J Nurs Midw 2019, 10(2):1059-1067 | DOI: 10.15452/CEJNM.2019.10.0014

Measures to prevent medication errors in intensive care units

Zuzana Plutínská1, Ilona Plevová2,*
1 Pediatric Intensive Care Unit, Hospital Frýdek-Místek, Czech Republic
2 Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Czech Republic

Aim: The aims were to summarize studies on the effectiveness of interventions to reduce adverse events of the medication error type and, based on the studies, to identify recommendations for preventing medication errors in intensive care units (ICUs).

Design: A descriptive review.

Methods: To find relevant resources, the SCOPUS and EBSCO electronic databases were searched using the following search words: prevention, medication errors, intensive care unit. Both primary and secondary studies on prevention of medication errors in ICUs were selected.

Results: A total of eight primary studies and three systematic reviews were included. The studies showed considerable variability and differed in methods, numbers of monitored events or ways of data collection. The assessed interventions were pharmacist involvement, automated infusion devices, reporting medication errors, strategies to limit interruptions during drug administration, electronic health records together with support systems for clinical decision making, nurse education in drug administration and creating checklists.

Conclusion: The assessment of selected studies suggests that to a certain extent, all of them showed certain medication error reduction. Due to numerous limitations, however, it is impossible to select and recommend a single approach.

Keywords: adverse event, intensive care, medication error, nursing, patient safety, prevention

Received: December 12, 2018; Accepted: May 10, 2019; Published: September 30, 2019  Show citation

ACS AIP APA ASA Harvard Chicago IEEE ISO690 MLA NLM Turabian Vancouver
Plutínská Z, Plevová I. Measures to prevent medication errors in intensive care units. Central European Journal of Nursing and Midwifery. 2019;10(2):1059-1067. doi: 10.15452/CEJNM.2019.10.0014.
Download citation

References

  1. About Medication Errors. NCCMERP © 2018 [cited 2017 Dec 21]. Available from: http://www.nccmerp.org/aboutmedication-errors/AHRQ.
  2. Medication Errors. Last revision 2017 Jun 1 [cited 2017 Dec 21]. Available from: http://psnet.ahrq.gov/primer.aspx?primerID=23
  3. Berdot S, Roudot M, Schramm C, Katsahian S, Durieux P, Sabatier B. Interventions to reduce nurses' medication administration errors in inpatient settings: A systematic review and meta-analysis. International Journal of Nursing Studies. 2016;53:342-350. Go to original source... Go to PubMed...
  4. Breeding J, Welch S, Whittam S, Buscher H, Burrows F, Frost C, Jonkman M, Mathews N, Wong KS, Wong A. Medication Error Minimization Scheme (MEMS) in an adult tertiary intensive care unit (ICU) 2009-2011. Australian Critical Care. 2013;26(2):58-75. Go to original source... Go to PubMed...
  5. Cima LE, Clarke S. The nurse's role in medication safety. 2nd ed. Illinois: Oakbrook Terrace; 2012.
  6. Connor JA, Ahern JP, Cuccovia B, Porter CL, Arnold A, Dionne RE, Hickey PA. Implementing a distraction-free practice with the red zone medication safety initiative. Dimensions of Critical Care Nursing. 2016;35(3):116-124. Go to original source... Go to PubMed...
  7. Cook MC. Nurses' six rights for safe medication administration. 1999 [cited 2018 Nov 27]. MNA © 2017. Available from: http://www.massnurses.org/nursingresources/nursing-practice/articles/six-rights
  8. Di Simone E, Tartaglini D, Fiorini S, Petriglieri S, Plocco C, Di Muzio M. Medication errors in intensive care units: nurses' training needs. Emergency Nurse. 2016;24(4):24-29. Go to original source... Go to PubMed...
  9. Durham ML, Suhayda R, Normand P, Jankiewicz A, Fogg L. Reducing medication administration errors in acute and critical care. JONA: The Journal of Nursing Administration. 2016;46(2):75-81. Go to original source... Go to PubMed...
  10. Flynn F, Evanish JQ, Fernald JM, Hutchinson DE, Lefaiver C. Progressive care nurses improving patient safety by limiting interruptions during medication administration. Critical Care Nurse. 2016;36(4):19-35. Go to original source... Go to PubMed...
  11. Hennings S, Romero A, Erstad BL, Franke H, Theodorou AA. A comparison of automated infusion device technology to prevent medication errors in pediatric and adult intensive care unit patients. Hospital Pharmacy. 2010;45(6):464-471. Go to original source...
  12. Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients. American Journal of Health-System Pharmacy. 2008;65(13):1254-1260. Go to original source... Go to PubMed...
  13. Keers NR, Williams SD, Cooke J, Ashcroft DM. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Safety. 2013;36(11):1045-1067. Go to original source... Go to PubMed...
  14. Kelblová K. Identifikace medikačního pochybení sestrou v rámci nácviku modelových situací. 87 p. Diplomová práce. Vedoucí diplomové práce Iva Brabcová. České Budějovice: Jihočeská univerzita v Českých Budějovicích, Zdravotně sociální fakulta, Katedra ošetřovatelství a porodní asistence; 2015. (in Czech)
  15. Liao TV, Rabinovich M, Abraham P, Perez S, DiPlotti C, Han JE, Martin GS, Honig E. Evaluation of medication errors with implementation of electronic health record technology in the medical intensive care unit. Open Access Journal of Clinical Trials. 2017;9:31-40. Go to original source...
  16. Machaczek KK, Whitfield M. Doporučené postupy v oblasti prevence a identifikace nežádoucích událostí v nemocnicích v České republice. 2012, 69 p. [cited 2017 Oct 1]. Available from: http://www.projecthope.cz/uploads/nil_nocere/PARTS1-7-pouze%20postupy-Aug15,2012.pdf (in Czech)
  17. Manias E, Williams A, Liew D. Interventions to reduce medication errors in adult intensive care: a systematic review. British Journal of Clinical Pharmacology. 2012;74(3):411- 423. Go to original source... Go to PubMed...
  18. Mikšová Z, Froňková M, Hernová R, Zajíčková M. Kapitoly z ošetřovatelské péče 1. Praha: Grada Publishing; 2006. (in Czech)
  19. MZČR. Resortní bezpečností cíle. 2015. MZČR © 2010. Last revison 2018 Jan 29 [cited 2018 Nov 27]. Available from: http://www.mzcr.cz/KvalitaABezpeci/obsah/resortnibezpecnostni-cile-_2922_29.html (in Czech)
  20. MZČR. Rádce pacienta. 2016. MZČR © 2010. Last revision 2016 Mar 2 [cited 2017 Dec 18]. Available from: http://www.mzcr.cz/KvalitaABezpeci/obsah/radcepacienta_2898_29.html (in Czech)
  21. Nguyen MR, Mosel C, Grzeskowiak LE. Interventions to reduce medication errors in neonatal care: a systematic review. Therapeutic Advances in Drug Safety. 2018;9(2):123-155. Go to original source... Go to PubMed...
  22. Nicholas PK, Agius CR. Toward safer IV medication administration: the narrow safety margins of many IV medications make this route particularly dangerous. American Journal of Nursing. 2005;105(3 Suppl):25-30. Go to original source... Go to PubMed...
  23. Oldřichová L. Kde jsou lidé, tam vznikají chyby [online]. Medical tribune. 2010;6(19). [cited 2018 May 23]. Available from: http://www.tribune.cz/clanek/19088-kde-jsou-lide-tamvznikaji-chyby (in Czech)
  24. Plischke S. V elektronizaci, a tedy i bezpečnosti, medikačního procesu za Evropou zaostáváme. In. ISSS 2015: 18. ročník konference ISSS, Hradec Králové 13. - 14. dubna 2015: sborník příspěvků konference [online]. © 2015 Triada, spol. s.r.o. [cited 2017 May 23]. Available from: https://www.isss.cz/archiv/2015/download/isss2015.pdf (in Czech)
  25. Richards A, Edwards S. Repetitorium pro zdravotní sestry. Praha: Grada Publishing, a.s.; 2004. (in Czech)
  26. Santesteban E, Arenas S, Campino A. Medication errors in neonatal care: a systematic review of types of errors and effectiveness of preventive strategies. Journal of Neonatal Nursing. 2015;21(5):200-208. Go to original source...
  27. Vondráček L, Vondráček J. Pochybení a sankce při poskytování ošetřovatelské péče II. Praha: Grada Publishing, a.s.; 2006. (in Czech)
  28. Vyhláška č. 84 ze dne 26. února 2008 o správné lékárenské praxi, bližších podmínkách zacházení s léčivy v lékárnách, zdravotnických zařízeních a u dalších provozovatelů a zařízení vydávajících léčivé přípravky. In. Sbírka zákonů, Česká republika. 2008, částka 25. (in Czech)
  29. Zákon č. 378 ze dne 6. prosince 2007 o léčivech. In. Sbírka zákonů České republiky. (in Czech)

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0), which permits non-comercial use, distribution, and reproduction in any medium, provided the original publication is properly cited. No use, distribution or reproduction is permitted which does not comply with these terms.