Paper reports were the most popular method (16/26 [62%]) for voluntary reporting of medication errors (Figure 2). Other methods were intranet, phone calls, and Internet (Figure 2). Netsafe, Meditech EMR, and Risk MonitorPro were reported as the web-based systems in use. An internal e-mail system built into the computer system was reported by one ICU.
Figure 2. Methods for voluntary reporting of medication errors and adverse drug events, as reported by survey respondents in Canadian intensive care units (n = 26 ICUs).
All ICUs that used trigger tools for chart review included voluntary reporting of medication errors as a trigger signal. Other trigger signals were abnormal drug levels, antidote use, use of allergy medications, low serum glucose level, other abnormal laboratory values, abrupt medication stop, and abnormal electrolyte concentrations.
Actions Taken as a Result of Measuring Medication Errors and/or Adverse Drug Events
Of the 26 ICUs that had a process for measuring medication errors, only 14 (54%) had implemented changes on the basis of this information, according to the ICU pharmacist respondents. Reported changes are listed in Box 1.