Medication Error Reporting Systems: RESULTS

25 Dec
2010

Responses were received from 34 pharmacists working in 31 ICUs. The survey response rate was 39% (31/79) in terms of the number of ICUs or 23% (34/146) in terms of the num­ber of respondents. Response rates by question, according to number of individuals responding, were 100% (34/34) for questions 1, 4, 5, and 6; 91% (31/34) for question 2; 97% (33/34) for question 3; 100% (2/2) for questions 7 and 13; 94% (32/34) for question 8; 100% (28/28) for questions 9, 10, 11, and 14; 100% (4/4) for question 12; and 50% (14/28) for question 15. For ICUs with more than one respondent, only the single most complete survey was analyzed.

Demographic CharacteristicsResponses were received from all provinces except Quebec, Prince Edward Island, and Newfoundland and Labrador. The 31 ICUs represented were fairly evenly split among academic hospitals (11 or 35%), community teaching hospitals (9 or 29%), and community nonteaching centres (11 or 35%). The majority of ICUs represented were mixed medical/surgical (23/31 [74%]); other types of ICU represented were neurologic, coronary, pediatric, medical, and a joint unit providing trauma, neurologic, burn, and cardiothoracic care. Thirteen (42%) of the 31 responding ICUs had 1-10 beds, 12 (39%) had 11-20 beds, and 6 (19%) had 21-30 beds. Twenty-seven (87%) of the responding ICUs had 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 during daytime hours. Most ICUs (29/31 [94%]) did not have computerized physician order entry. Of the 2 (6%) hospitals that did have this capability, only 1 (50%) also had decision support software.
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Figure 1. Methods used

Figure 1. Methods used for measuring medication errors and adverse drug events, as reported by survey respondents in Canadian intensive care units (n = 26 ICUs).

Measurement of Medication Errors and Adverse Drug Events

Twenty-six (90%) of the 29 ICUs that responded to this question had a method for tracking medication errors and adverse events. Of these, 24 (92%) used the same method throughout the hospital; the remainder used a method that was specific to the ICU. Non-anonymous and anonymous volun­tary reporting and direct observation were the most common methods used to measure medication errors and adverse drug events in these ICUs (Figure 1). Other methods were chart review, trigger tools, tracking of pharmacist interventions, and ICU “safety huddles”. Twenty (77%) of the 26 ICUs that had a method for measuring errors and adverse drug events reported using more than one method. The most common combinations of methods were non-anonymous and anonymous voluntary reporting, voluntary reporting and direct observation, and voluntary reporting, direct observation, and chart review. canadian antibiotics

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