In response to: Bohomol E., Ramos LH., D’Innocenzo M. (2009) Medication errors in an intensive care unit. Journal of Advanced Nursing, 65(6), 1259–1267.
Medication errors in an intensive care unit: systems, pressures and prioritizing
The compelling article by Bohomol et al. (2009) describes medication errors in intensive care and offers insight into sources of errors. Medication errors have been defined as ‘any preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer. Such events may be related to professional practice, healthcare products, procedures and systems, including prescribing; order communication; product labelling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring and use’ (NCC MERP 2005, p. 4). Although several professionals may be involved in medication errors, nurses are the professionals closest to the patient and the final link in the medication chain.
Patient safety is a recognized priority for healthcare organizations and professionals, but there are underlying weaknesses in current medication practice (NPSA 2007). The true incidence of errors in preparation and administration of medicines is unknown. From the relatively few data papers published, estimates for errors of varying clinical importance, range from 24% to 94% of doses administered, according to Hoefel et al.’s (2008) review. The variation may be explained by different research designs, settings and categorizations of errors and is compounded by the under-reporting of medication errors in routine data collection systems.
Systems engender errors
Bohomol et al. found in their own study, conducted in South America, that most patients reviewed (40/44, 91%) were subjected to at least one medication error. Most errors (172/305, 57%) fell into a category rarely seen in Northern Europe namely, that the medicine was not available in the pharmacy or even the institution. The second most prevalent category, transcription errors (33/305, 11%), would also be unfamiliar to many nurses. The process of doctors’ prescriptions (electronic or handwritten) being copied out by clerical staff is a source of error rarely discussed in the medication error literature. The remaining errors (84/305) identified by Bohomol et al. are more familiar, and included illegible prescriptions, wrong doses errors and confusion over route of administration.
Both the novel sources of error identified here relate to bureaucracy that operates in healthcare systems. This important finding should be considered in relation to prescribing systems in other contexts. Any new prescribing systems need to combat all recognized sources of error. New technologies mean new systems and new bureaucracies, all with potential for new errors. Technical advances may reduce old errors, but, without careful monitoring and evaluation, may come at the expense of introducing new and unsuspected system weaknesses and failures: new technologies are no substitute for professional knowledge and systematized practice based on that knowledge.
Pressures in the workplace
In Bohomol et al.’s study, systems’ failures were the commonest underlying cause of drug errors, but workplace pressures were also featured: for example, length of stay, bed occupancy and mortality rates were all higher than in other intensive care units in Brazil and may have contributed to staff stress, errors and, consequently, adverse patient outcome.
The error-safety nexus is an uncomfortable and controversial place for researchers, particularly fieldworkers. Not all errors cause patient harm. However, in the UK 10,303 of 59,802 medication incidents (17.2%) voluntarily reported in 2005–2006 were described as resulting in harm and 58 deaths were attributed to medication error (NPSA 2007). Given the nature of some errors described by Bohomol et al., including omission of doses of antibiotics, anticoagulants, inotropes and anaesthetics, there could be longer-term sequelae. Random fluctuations in antibiotic concentrations due to errors of dose omission or timing are likely to promote the development of drug-resistant microorganisms, but quantification of this problem will require long-term research funding. It is not always possible to attribute responsibility for omitted doses. However, nurses may be responsible for the decision not to act to prevent a dose omission. Sometimes ‘the drug has not come up from pharmacy yet’ and the nurse feels that there is no time to collect it or ‘the patient is not on the ward’ and neither was the medicine sent with the patient, nor is there time to take the medicine to another part of the hospital. Is such prioritization a reflection of inadequate professional education?
Prioritizing and professional education
Bohomol et al.’s study is the first to demonstrate the importance to teachers and researchers of addressing errors both of commission and of omission in the administration and monitoring of medicines. The five rights of medication administration (right patient, drug, dose, route, time) have served as a useful mantra for decades, but too often have been viewed as the limits of nursing involvement with pharmacology. Any such constraints are not in the interests of patient safety. Reviews indicate that omitted or inadequate monitoring for adverse drug reactions is responsible for 10–60% of medication errors and adverse drug reactions, depending on the clinical setting (NCC MERP 2005, Jordan 2007). The identification of this ‘care gap’ suggests that there is potential to expand nurses’ engagement with medication administration to encompass adverse event monitoring, defined as observing or recording physiological or psychological signs and symptoms relevant to the drugs administered (NCC MERP 2005, p. 30).
Other authors have found knowledge deficit to be the commonest cause of medication error (Kopp et al. 2006). Professionals rely on effective educational preparation to prioritize workloads safely and effectively. Medication errors of commission and omission can have disastrous consequences for patients’ safety and professionals’ careers. For example, any delay in administering time-dependent antibiotics, including those prescribed to treat life-threatening infections, such as penicillins, carbapenems, monobactams, erythromycin, linezolid and vancomycin, can result in sub-therapeutic drug concentrations and therapeutic failure; delay in administration of some antidepressants can trigger a withdrawal response of headache, anxiety, agitation or restlessness; and if a dose of an anti-epileptic drug is delayed or omitted, the patient may experience a fit 2–3 days later. Bohomol et al. have identified an important ‘care gap’, which should be addressed. Investment in nurse education and research that focuses on the increasing professional responsibility and complexity of modern therapeutic regimens is likely to yield substantial gains in terms of patient safety and clinical outcome.