Medication Error Reporting Systems: DISCUSSION

27 Dec
2010

This survey was the first to systematically examine the reporting of medication errors and adverse drug events in Canadian ICUs. Responses came from a wide variety of Canadian ICUs, and only 3 provinces were not represented. Responses were obtained almost equally from academic, community teaching, and community nonteaching hospitals. In a similar recently reported survey of ICUs in the United States, most respondents were from nonteaching community institutions. Because of this difference in the responding population, the findings from the US survey may not be applicable to Canadian ICUs and may explain differences such as the rate of use of voluntary reporting systems (94.7% in the US study compared to 73% in this Canadian survey).

The majority of Canadian ICUs that responded to this survey reported having a pharmacist who was familiar with the patients’ conditions and who reviewed the patients’ drug therapy with the ICU team at least 5 days per week. Having a critical care pharmacist who fulfils these roles has been associated with better outcomes for patients. Although a pharmacist was present in the majority of responding ICUs, only a few of the units used pharmacist interventions as a method of tracking medication errors. This suggests that critical care pharmacists are not being used to their full potential, which may include the detection, interception, reporting, and resolution of medication errors and adverse drug events. Viagra Super Active

The wide range of methods of measuring medication errors and adverse drug events reported by the respondents to this survey indicates that there is no standard for such measurement in Canadian ICUs. As well, reliance on voluntary reporting may indicate that rates of medication errors and adverse events in Canadian ICUs are underestimated. Jha and others reported that chart review or computer-based monitoring led to the identification of more medication errors than did voluntary reporting. This may relate to lack of time to complete voluntary reports or fear of punitive action after voluntary reporting.

One of the more surprising results from this study was that 10% (3/29) of responding ICUs did not have any method for tracking medication errors and/or adverse events. Farley and others reported similarly that 13% of the hospitals they surveyed did not have a patient safety program. These results suggest that some ICUs do not address medication errors and adverse drug events at all. This situation is particularly alarming given that the rates and severity of adverse drug events are more severe among ICU patients than among patients in other areas of the hospital. Although the majority of ICUs used a method to measure medication errors and adverse drug events, only 54% had made changes in response to reports of such events. Areas where changes could be made include technical and organizational strategies. Technical strategies include choices and restriction of antibiotics, nomograms for the use of heparin and insulin, and sedation protocols. Organizational strategies include using checklists of safety tasks during ICU rounds, preventing fatigue among providers by implementing sensible call schedules, utilizing the expertise of ICU pharmacists as described above, and having a systematic approach to quality improvement based on reports of medication errors and adverse events.
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