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Published in: Critical Care 2/2008

01-04-2008 | Review

Clinical review: Medication errors in critical care

Authors: Eric Moyen, Eric Camiré, Henry Thomas Stelfox

Published in: Critical Care | Issue 2/2008

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Abstract

Medication errors in critical care are frequent, serious, and predictable. Critically ill patients are prescribed twice as many medications as patients outside of the intensive care unit (ICU) and nearly all will suffer a potentially life-threatening error at some point during their stay. The aim of this article is to provide a basic review of medication errors in the ICU, identify risk factors for medication errors, and suggest strategies to prevent errors and manage their consequences.
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Literature
2.
go back to reference Kohn LT, Corrigan JM, Donaldson MS: To Err is Human: Building a Safer Health System. 1999, Washington: National Academy Press Kohn LT, Corrigan JM, Donaldson MS: To Err is Human: Building a Safer Health System. 1999, Washington: National Academy Press
3.
go back to reference Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW: The 'To Err is Human' report and the patient safety literature. Qual Saf Health Care. 2006, 15: 174-178. 10.1136/qshc.2006.017947.PubMedPubMedCentralCrossRef Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW: The 'To Err is Human' report and the patient safety literature. Qual Saf Health Care. 2006, 15: 174-178. 10.1136/qshc.2006.017947.PubMedPubMedCentralCrossRef
4.
go back to reference Leape LL, Berwick DM: Five years after To Err Is Human: what have we learned?. JAMA. 2005, 293: 2384-2390. 10.1001/jama.293.19.2384.PubMedCrossRef Leape LL, Berwick DM: Five years after To Err Is Human: what have we learned?. JAMA. 2005, 293: 2384-2390. 10.1001/jama.293.19.2384.PubMedCrossRef
5.
go back to reference Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov R, Cotev S: A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995, 23: 294-300. 10.1097/00003246-199502000-00015.PubMedCrossRef Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov R, Cotev S: A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995, 23: 294-300. 10.1097/00003246-199502000-00015.PubMedCrossRef
6.
go back to reference Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Morlock LL: Defining and measuring patient safety. Crit Care Clin. 2005, 21: 1-19. 10.1016/j.ccc.2004.07.006.PubMedCrossRef Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Morlock LL: Defining and measuring patient safety. Crit Care Clin. 2005, 21: 1-19. 10.1016/j.ccc.2004.07.006.PubMedCrossRef
7.
go back to reference Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, Stone PH, Lilly CM, Katz JT, Czeisler CA, Bates DW: The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005, 33: 1694-1700. 10.1097/01.CCM.0000171609.91035.BD.PubMedCrossRef Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, Stone PH, Lilly CM, Katz JT, Czeisler CA, Bates DW: The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005, 33: 1694-1700. 10.1097/01.CCM.0000171609.91035.BD.PubMedCrossRef
8.
go back to reference Pharmacy-nursing shared vision for safe medication use in hospitals: executive summary session. Am J Health Syst Pharm. 2003, 60: 1046-1052. Pharmacy-nursing shared vision for safe medication use in hospitals: executive summary session. Am J Health Syst Pharm. 2003, 60: 1046-1052.
9.
go back to reference Hussain E, Kao E: Medication safety and transfusion errors in the ICU and beyond. Crit Care Clin. 2005, 21: 91-110. 10.1016/j.ccc.2004.08.003.PubMedCrossRef Hussain E, Kao E: Medication safety and transfusion errors in the ICU and beyond. Crit Care Clin. 2005, 21: 91-110. 10.1016/j.ccc.2004.08.003.PubMedCrossRef
10.
go back to reference Leape LL: Preventing adverse drug events. Am J Health Syst Pharm. 1995, 52: 379-382.PubMed Leape LL: Preventing adverse drug events. Am J Health Syst Pharm. 1995, 52: 379-382.PubMed
11.
go back to reference Krahenbuhl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krahenbuhl S: Drug-related problems in hospitals: a review of the recent literature. Drug Safety. 2007, 30: 379-407. 10.2165/00002018-200730050-00003.PubMedCrossRef Krahenbuhl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krahenbuhl S: Drug-related problems in hospitals: a review of the recent literature. Drug Safety. 2007, 30: 379-407. 10.2165/00002018-200730050-00003.PubMedCrossRef
12.
go back to reference Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R: Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995, 274: 29-34. 10.1001/jama.274.1.29.PubMedCrossRef Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R: Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995, 274: 29-34. 10.1001/jama.274.1.29.PubMedCrossRef
13.
go back to reference Calabrese AD, Erstad BL, Brandl K, Barletta JF, Kane SL, Sherman DS: Medication administration errors in adult patients in the ICU. Intensive Care Med. 2001, 27: 1592-1598. 10.1007/s001340101065.PubMedCrossRef Calabrese AD, Erstad BL, Brandl K, Barletta JF, Kane SL, Sherman DS: Medication administration errors in adult patients in the ICU. Intensive Care Med. 2001, 27: 1592-1598. 10.1007/s001340101065.PubMedCrossRef
14.
go back to reference Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey R, Ives J, Laird N, Laffel G, Nemeskal R, Petersen LA, Porter K, Servi D, Shea BF, Small SD, Sweitzer BJ, Thompson T, Vander Vliet M, for the ADE Prevention Study Group: Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995, 274: 35-43. 10.1001/jama.274.1.35.PubMedCrossRef Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey R, Ives J, Laird N, Laffel G, Nemeskal R, Petersen LA, Porter K, Servi D, Shea BF, Small SD, Sweitzer BJ, Thompson T, Vander Vliet M, for the ADE Prevention Study Group: Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995, 274: 35-43. 10.1001/jama.274.1.35.PubMedCrossRef
15.
go back to reference The United States Pharmacopeial Convention: 1999. 1999, Rockville, MD: United States Pharmacopeia, 1131-1132. The United States Pharmacopeial Convention: 1999. 1999, Rockville, MD: United States Pharmacopeia, 1131-1132.
16.
go back to reference Parshuram CS, Ng GYT, Ho TKL, Klein J, Moore AM, Bohn D, Koren G: Discrepancies between ordered and delivered concentrations of opiate infusions in critical care. Crit Care Med. 2003, 31: 2483-2487. 10.1097/01.CCM.0000089638.83803.B2.PubMedCrossRef Parshuram CS, Ng GYT, Ho TKL, Klein J, Moore AM, Bohn D, Koren G: Discrepancies between ordered and delivered concentrations of opiate infusions in critical care. Crit Care Med. 2003, 31: 2483-2487. 10.1097/01.CCM.0000089638.83803.B2.PubMedCrossRef
17.
18.
go back to reference McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA: The quality of health care delivered to adults in the United States. N Engl J Med. 2003, 348: 2635-2645. 10.1056/NEJMsa022615.PubMedCrossRef McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA: The quality of health care delivered to adults in the United States. N Engl J Med. 2003, 348: 2635-2645. 10.1056/NEJMsa022615.PubMedCrossRef
19.
go back to reference Kanjanarat P, Winterstein AG, Johns TE, Hatton RC, Gonzalez-Rothi R, Segal R: Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm. 2003, 60: 1750-1759.PubMed Kanjanarat P, Winterstein AG, Johns TE, Hatton RC, Gonzalez-Rothi R, Segal R: Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm. 2003, 60: 1750-1759.PubMed
20.
go back to reference Kane-Gill S, Weber RJ: Principles and practices of medication safety in the ICU. Crit Care Clin. 2006, 22: 273-290. 10.1016/j.ccc.2006.02.005.PubMedCrossRef Kane-Gill S, Weber RJ: Principles and practices of medication safety in the ICU. Crit Care Clin. 2006, 22: 273-290. 10.1016/j.ccc.2006.02.005.PubMedCrossRef
21.
go back to reference Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ: Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care. 2007, 16: 116-126. 10.1136/qshc.2006.019950.PubMedPubMedCentralCrossRef Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ: Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care. 2007, 16: 116-126. 10.1136/qshc.2006.019950.PubMedPubMedCentralCrossRef
22.
go back to reference O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA: Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993, 119: 370-376.PubMedCrossRef O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA: Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993, 119: 370-376.PubMedCrossRef
23.
go back to reference Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL: Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002, 59: 436-446.PubMed Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL: Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002, 59: 436-446.PubMed
24.
go back to reference Michel P, Quenon JL, de Sarasqueta AM, Scemama O: Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ. 2004, 328: 199-10.1136/bmj.328.7433.199.PubMedPubMedCentralCrossRef Michel P, Quenon JL, de Sarasqueta AM, Scemama O: Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ. 2004, 328: 199-10.1136/bmj.328.7433.199.PubMedPubMedCentralCrossRef
25.
go back to reference Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, Siegler M: An alternative strategy for studying adverse events in medical care. Lancet. 1997, 349: 309-313. 10.1016/S0140-6736(96)08268-2.PubMedCrossRef Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, Siegler M: An alternative strategy for studying adverse events in medical care. Lancet. 1997, 349: 309-313. 10.1016/S0140-6736(96)08268-2.PubMedCrossRef
26.
go back to reference Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L: Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995, 10: 199-205. 10.1007/BF02600255.PubMedCrossRef Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L: Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995, 10: 199-205. 10.1007/BF02600255.PubMedCrossRef
27.
go back to reference Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL: Medication errors observed in 36 health care facilities. Arch Intern Med. 2002, 162: 1897-1903. 10.1001/archinte.162.16.1897.PubMedCrossRef Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL: Medication errors observed in 36 health care facilities. Arch Intern Med. 2002, 162: 1897-1903. 10.1001/archinte.162.16.1897.PubMedCrossRef
28.
go back to reference Tissot E, Cornette C, Demoly P, Jacquet M, Barale F, Capellier G: Medication errors at the administration stage in an intensive care unit. Intensive Care Med. 1999, 25: 353-359. 10.1007/s001340050857.PubMedCrossRef Tissot E, Cornette C, Demoly P, Jacquet M, Barale F, Capellier G: Medication errors at the administration stage in an intensive care unit. Intensive Care Med. 1999, 25: 353-359. 10.1007/s001340050857.PubMedCrossRef
29.
go back to reference Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP: Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997, 277: 301-306. 10.1001/jama.277.4.301.PubMedCrossRef Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP: Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997, 277: 301-306. 10.1001/jama.277.4.301.PubMedCrossRef
30.
go back to reference Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, Seger DL: Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998, 280: 1311-1316. 10.1001/jama.280.15.1311.PubMedCrossRef Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, Seger DL: Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998, 280: 1311-1316. 10.1001/jama.280.15.1311.PubMedCrossRef
31.
go back to reference Cohen H, Mandrack MM: Application of the 80/20 rule in safeguarding the use of high-alert medications. Crit Care Nurs Clin North Am. 2002, 14: 369-374. 10.1016/S0899-5885(02)00018-7.PubMedCrossRef Cohen H, Mandrack MM: Application of the 80/20 rule in safeguarding the use of high-alert medications. Crit Care Nurs Clin North Am. 2002, 14: 369-374. 10.1016/S0899-5885(02)00018-7.PubMedCrossRef
32.
go back to reference Christensen JF, Levinson W, Dunn PM: The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992, 7: 424-431. 10.1007/BF02599161.PubMedCrossRef Christensen JF, Levinson W, Dunn PM: The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992, 7: 424-431. 10.1007/BF02599161.PubMedCrossRef
33.
go back to reference Pronovost PJ, Weast B, Holzmueller CG, Rosenstein BJ, Kidwell RP, Haller KB, Feroli ER, Sexton JB, Rubin HR: Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care. 2003, 12: 405-410. 10.1136/qhc.12.6.405.PubMedPubMedCentralCrossRef Pronovost PJ, Weast B, Holzmueller CG, Rosenstein BJ, Kidwell RP, Haller KB, Feroli ER, Sexton JB, Rubin HR: Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care. 2003, 12: 405-410. 10.1136/qhc.12.6.405.PubMedPubMedCentralCrossRef
34.
go back to reference Giraud T, Dhainaut JF, Vaxelaire JF, Joseph T, Journois D, Bleichner G, Sollet JP, Chevret S, Monsallier JF: Iatrogenic complications in adult intensive care units: a prospective two-center study. Crit Care Med. 1993, 21: 40-51. 10.1097/00003246-199301000-00011.PubMedCrossRef Giraud T, Dhainaut JF, Vaxelaire JF, Joseph T, Journois D, Bleichner G, Sollet JP, Chevret S, Monsallier JF: Iatrogenic complications in adult intensive care units: a prospective two-center study. Crit Care Med. 1993, 21: 40-51. 10.1097/00003246-199301000-00011.PubMedCrossRef
35.
go back to reference Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL: Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997, 25: 1289-1297. 10.1097/00003246-199708000-00014.PubMedCrossRef Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL: Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997, 25: 1289-1297. 10.1097/00003246-199708000-00014.PubMedCrossRef
36.
go back to reference Ridley SA, Booth SA, Thompson CM, Clayton T, Eddleston J, Mackenzie S, Thomas T, Webb A, Wright D: Prescription errors in UK critical care units. Anaesthesia. 2004, 59: 1193-1200. 10.1111/j.1365-2044.2004.03969.x.PubMedCrossRef Ridley SA, Booth SA, Thompson CM, Clayton T, Eddleston J, Mackenzie S, Thomas T, Webb A, Wright D: Prescription errors in UK critical care units. Anaesthesia. 2004, 59: 1193-1200. 10.1111/j.1365-2044.2004.03969.x.PubMedCrossRef
37.
go back to reference Kollef MH, Sherman G, Ward S, Fraser VJ: Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999, 115: 462-474. 10.1378/chest.115.2.462.PubMedCrossRef Kollef MH, Sherman G, Ward S, Fraser VJ: Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999, 115: 462-474. 10.1378/chest.115.2.462.PubMedCrossRef
38.
go back to reference Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH: The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000, 118: 146-155. 10.1378/chest.118.1.146.PubMedCrossRef Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH: The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000, 118: 146-155. 10.1378/chest.118.1.146.PubMedCrossRef
39.
go back to reference Campbell AJ, Bloomfield R, Noble DW: An observational study of changes to long-term medication after admission to an intensive care unit. Anaesthesia. 2006, 61: 1087-1092. 10.1111/j.1365-2044.2006.04831.x.PubMedCrossRef Campbell AJ, Bloomfield R, Noble DW: An observational study of changes to long-term medication after admission to an intensive care unit. Anaesthesia. 2006, 61: 1087-1092. 10.1111/j.1365-2044.2006.04831.x.PubMedCrossRef
40.
go back to reference Larsen GY, Parker HB, Cash J, O'Connell M, Grant MC: Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005, 116: e21-25. 10.1542/peds.2004-2452.PubMedCrossRef Larsen GY, Parker HB, Cash J, O'Connell M, Grant MC: Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005, 116: e21-25. 10.1542/peds.2004-2452.PubMedCrossRef
41.
go back to reference Bullock J, Jordan D, Gawlinski A, Henneman EA: Standardizing IV infusion medication concentrations to reduce variability in medication errors. Crit Care Nurs Clin North Am. 2006, 18: 515-521. 10.1016/j.ccell.2006.08.008.PubMedCrossRef Bullock J, Jordan D, Gawlinski A, Henneman EA: Standardizing IV infusion medication concentrations to reduce variability in medication errors. Crit Care Nurs Clin North Am. 2006, 18: 515-521. 10.1016/j.ccell.2006.08.008.PubMedCrossRef
42.
go back to reference Shamliyan TA, Duval S, Du J, Kane RL: Just what the doctor ordered. Review of the evidence of the impact of computerized physician order entry system on medication errors. Health Serv Res. 2008, 43 (1 Pt 1): 32-53.PubMedPubMedCentral Shamliyan TA, Duval S, Du J, Kane RL: Just what the doctor ordered. Review of the evidence of the impact of computerized physician order entry system on medication errors. Health Serv Res. 2008, 43 (1 Pt 1): 32-53.PubMedPubMedCentral
43.
go back to reference Eslami S, Abu-Hanna A, De Keizer NF, De Jonge E: Errors associated with applying decision support by suggesting default doses for aminoglycosides. Drug Safety. 2006, 29: 803-809. 10.2165/00002018-200629090-00004.PubMedCrossRef Eslami S, Abu-Hanna A, De Keizer NF, De Jonge E: Errors associated with applying decision support by suggesting default doses for aminoglycosides. Drug Safety. 2006, 29: 803-809. 10.2165/00002018-200629090-00004.PubMedCrossRef
44.
go back to reference Williams CK, Maddox RR: Implementation of an i.v. medication safety system. Am J Health Syst Pharm. 2005, 62: 530-536.PubMed Williams CK, Maddox RR: Implementation of an i.v. medication safety system. Am J Health Syst Pharm. 2005, 62: 530-536.PubMed
45.
go back to reference Cummings J, Bush P, Smith D, Matuszewski K: Bar-coding medication administration overview and consensus recommendations. Am J Health Syst Pharm. 2005, 62: 2626-2629. 10.2146/ajhp050222.PubMedCrossRef Cummings J, Bush P, Smith D, Matuszewski K: Bar-coding medication administration overview and consensus recommendations. Am J Health Syst Pharm. 2005, 62: 2626-2629. 10.2146/ajhp050222.PubMedCrossRef
46.
go back to reference Pronovost P, Weast B, Schwarz M, Wyskiel RM, Prow D, Milanovich SN, Berenholtz S, Dorman T, Lipsett P: Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care. 2003, 18: 201-205. 10.1016/j.jcrc.2003.10.001.PubMedCrossRef Pronovost P, Weast B, Schwarz M, Wyskiel RM, Prow D, Milanovich SN, Berenholtz S, Dorman T, Lipsett P: Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care. 2003, 18: 201-205. 10.1016/j.jcrc.2003.10.001.PubMedCrossRef
48.
go back to reference Weant KA, Cook AM, Armitstead JA: Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry. Am J Health Syst Pharm. 2007, 64: 526-530. 10.2146/ajhp060001.PubMedCrossRef Weant KA, Cook AM, Armitstead JA: Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry. Am J Health Syst Pharm. 2007, 64: 526-530. 10.2146/ajhp060001.PubMedCrossRef
49.
go back to reference Eslami S, Keizer NF, Abu-Hanna A: The impact of computerized physician medication order entry in hospitalized patients-A systematic review. Int J Med Inform. 2007, Nov 17, Eslami S, Keizer NF, Abu-Hanna A: The impact of computerized physician medication order entry in hospitalized patients-A systematic review. Int J Med Inform. 2007, Nov 17,
50.
go back to reference Ash JS, Gorman PN, Seshadri V, Hersh WR: Computerized physician order entry in U.S. hospitals: results of a 2002 survey. J Am Med Inform Assoc. 2004, 11: 95-99. 10.1197/jamia.M1427.PubMedPubMedCentralCrossRef Ash JS, Gorman PN, Seshadri V, Hersh WR: Computerized physician order entry in U.S. hospitals: results of a 2002 survey. J Am Med Inform Assoc. 2004, 11: 95-99. 10.1197/jamia.M1427.PubMedPubMedCentralCrossRef
51.
go back to reference Bell CM, Rahimi-Darabad P, Orner AI: Discontinuity of chronic medications in patients discharged from the intensive care unit. J Gen Intern Med. 2006, 21: 937-941. 10.1007/BF02743141.PubMedPubMedCentralCrossRef Bell CM, Rahimi-Darabad P, Orner AI: Discontinuity of chronic medications in patients discharged from the intensive care unit. J Gen Intern Med. 2006, 21: 937-941. 10.1007/BF02743141.PubMedPubMedCentralCrossRef
52.
go back to reference Stampi C: Ultrashort sleep/wake patterns and sustained performance. Sleep and Alertness: Chronobiological, Behavioral, and Medical Aspects of Napping. Edited by: Dinges DFB, Broughton RJ. 1989, New York: Raven Press, 456- Stampi C: Ultrashort sleep/wake patterns and sustained performance. Sleep and Alertness: Chronobiological, Behavioral, and Medical Aspects of Napping. Edited by: Dinges DFB, Broughton RJ. 1989, New York: Raven Press, 456-
53.
go back to reference Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA: Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004, 351: 1838-1848. 10.1056/NEJMoa041406.PubMedCrossRef Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA: Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004, 351: 1838-1848. 10.1056/NEJMoa041406.PubMedCrossRef
55.
go back to reference Lesar TS, Briceland LL, Delcoure K, Parmalee JC, Masta-Gornic V, Pohl H: Medication prescribing errors in a teaching hospital. JAMA. 1990, 263: 2329-2334. 10.1001/jama.263.17.2329.PubMedCrossRef Lesar TS, Briceland LL, Delcoure K, Parmalee JC, Masta-Gornic V, Pohl H: Medication prescribing errors in a teaching hospital. JAMA. 1990, 263: 2329-2334. 10.1001/jama.263.17.2329.PubMedCrossRef
56.
go back to reference LaPointe NM, Jollis JG: Medication errors in hospitalized cardiovascular patients. Arch Intern Med. 2003, 163: 1461-1466. 10.1001/archinte.163.12.1461.PubMedCrossRef LaPointe NM, Jollis JG: Medication errors in hospitalized cardiovascular patients. Arch Intern Med. 2003, 163: 1461-1466. 10.1001/archinte.163.12.1461.PubMedCrossRef
57.
go back to reference Wasserfallen JB, Butschi AJ, Muff P, Biollaz J, Schaller MD, Pannatier A, Revelly JP, Chiolero R: Format of medical order sheet improves security of antibiotics prescription: The experience of an intensive care unit. Crit Care Med. 2004, 32: 655-659. 10.1097/01.CCM.0000114835.97789.AB.PubMedCrossRef Wasserfallen JB, Butschi AJ, Muff P, Biollaz J, Schaller MD, Pannatier A, Revelly JP, Chiolero R: Format of medical order sheet improves security of antibiotics prescription: The experience of an intensive care unit. Crit Care Med. 2004, 32: 655-659. 10.1097/01.CCM.0000114835.97789.AB.PubMedCrossRef
58.
go back to reference Van Den Bemt PMLA, Fijn R, Van Der Voort PHJ, Gossen AA, Egberts TCG, Brouwers JRBJ: Frequency and determinants of drug administration errors in the intensive care unit. Crit Care Med. 2002, 30: 846-850. 10.1097/00003246-200204000-00022.PubMedCrossRef Van Den Bemt PMLA, Fijn R, Van Der Voort PHJ, Gossen AA, Egberts TCG, Brouwers JRBJ: Frequency and determinants of drug administration errors in the intensive care unit. Crit Care Med. 2002, 30: 846-850. 10.1097/00003246-200204000-00022.PubMedCrossRef
59.
go back to reference Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL: Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002, 288: 2151-2162. 10.1001/jama.288.17.2151.PubMedCrossRef Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL: Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002, 288: 2151-2162. 10.1001/jama.288.17.2151.PubMedCrossRef
60.
go back to reference Durbin CG: Team model: advocating for the optimal method of care delivery in the intensive care unit. Crit Care Med. 2006, 34 (3 Suppl): S12-17. 10.1097/01.CCM.0000199985.72497.D1.PubMedCrossRef Durbin CG: Team model: advocating for the optimal method of care delivery in the intensive care unit. Crit Care Med. 2006, 34 (3 Suppl): S12-17. 10.1097/01.CCM.0000199985.72497.D1.PubMedCrossRef
61.
go back to reference Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H: The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991, 324: 377-384.PubMedCrossRef Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H: The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991, 324: 377-384.PubMedCrossRef
62.
go back to reference Bjornson DC, Hiner WO, Potyk RP, Nelson BA, Lombardo FA, Morton TA, Larson LV, Martin BP, Sikora RG, Cammarata FA: Effect of pharmacists on health care outcomes in hospitalized patients. Am J Hosp Pharm. 1993, 50: 1875-1884.PubMed Bjornson DC, Hiner WO, Potyk RP, Nelson BA, Lombardo FA, Morton TA, Larson LV, Martin BP, Sikora RG, Cammarata FA: Effect of pharmacists on health care outcomes in hospitalized patients. Am J Hosp Pharm. 1993, 50: 1875-1884.PubMed
63.
go back to reference Boyko WL, Yurkowski PJ, Ivey MF, Armitstead JA, Roberts BL: Pharmacist influence on economic and morbidity outcomes in a tertiary care teaching hospital. Am J Health Syst Pharm. 1997, 54: 1591-1595.PubMed Boyko WL, Yurkowski PJ, Ivey MF, Armitstead JA, Roberts BL: Pharmacist influence on economic and morbidity outcomes in a tertiary care teaching hospital. Am J Health Syst Pharm. 1997, 54: 1591-1595.PubMed
64.
go back to reference Bond CA, Raehl CL: Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy. 2007, 27: 481-493. 10.1592/phco.27.4.481.PubMedCrossRef Bond CA, Raehl CL: Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy. 2007, 27: 481-493. 10.1592/phco.27.4.481.PubMedCrossRef
65.
go back to reference Montazeri M, Cook DJ: Impact of a clinical pharmacist in a multidisciplinary intensive care unit. Crit Care Med. 1994, 22: 1044-1048. 10.1097/00003246-199406000-00027.PubMedCrossRef Montazeri M, Cook DJ: Impact of a clinical pharmacist in a multidisciplinary intensive care unit. Crit Care Med. 1994, 22: 1044-1048. 10.1097/00003246-199406000-00027.PubMedCrossRef
66.
go back to reference Baldinger SL, Chow MS, Gannon RH, Kelly ET: Cost savings from having a clinical pharmacist work part-time in a medical intensive care unit. Am J Health Syst Pharm. 1997, 54: 2811-2814.PubMed Baldinger SL, Chow MS, Gannon RH, Kelly ET: Cost savings from having a clinical pharmacist work part-time in a medical intensive care unit. Am J Health Syst Pharm. 1997, 54: 2811-2814.PubMed
67.
go back to reference Beckmann U, Baldwin I, Durie M, Morrison A, Shaw L: Problems associated with nursing staff shortage: an analysis of the first 3600 incident reports submitted to the Australian Incident Monitoring Study (AIMS-ICU). Anaesth Intensive Care. 1998, 26: 396-400.PubMed Beckmann U, Baldwin I, Durie M, Morrison A, Shaw L: Problems associated with nursing staff shortage: an analysis of the first 3600 incident reports submitted to the Australian Incident Monitoring Study (AIMS-ICU). Anaesth Intensive Care. 1998, 26: 396-400.PubMed
68.
go back to reference Whitman GR, Kim Y, Davidson LJ, Wolf GA, Wang SL: The impact of staffing on patient outcomes across specialty units. J Nurs Adm. 2002, 32: 633-639. 10.1097/00005110-200212000-00008.PubMedCrossRef Whitman GR, Kim Y, Davidson LJ, Wolf GA, Wang SL: The impact of staffing on patient outcomes across specialty units. J Nurs Adm. 2002, 32: 633-639. 10.1097/00005110-200212000-00008.PubMedCrossRef
69.
go back to reference Pronovost P, Wu AW, Dorman T, Morlock L: Building safety into ICU care. J Crit Care. 2002, 17: 78-85. 10.1053/jcrc.2002.34363.PubMedCrossRef Pronovost P, Wu AW, Dorman T, Morlock L: Building safety into ICU care. J Crit Care. 2002, 17: 78-85. 10.1053/jcrc.2002.34363.PubMedCrossRef
70.
go back to reference Hanneman SK: Advancing nursing practice with a unit-based clinical expert. Image J Nurs Sch. 1996, 28: 331-337. 10.1111/j.1547-5069.1996.tb00383.x.PubMedCrossRef Hanneman SK: Advancing nursing practice with a unit-based clinical expert. Image J Nurs Sch. 1996, 28: 331-337. 10.1111/j.1547-5069.1996.tb00383.x.PubMedCrossRef
72.
go back to reference Al-Ansari MA, Hijazi MH: Medical errors and adverse events: focus on the intensive care unit. Clinical Intensive Care. 2006, 17: 9-17. 10.1080/09563070600576196.CrossRef Al-Ansari MA, Hijazi MH: Medical errors and adverse events: focus on the intensive care unit. Clinical Intensive Care. 2006, 17: 9-17. 10.1080/09563070600576196.CrossRef
73.
go back to reference Bion JF, Heffner JE: Challenges in the care of the acutely ill. Lancet. 2004, 363: 970-977. 10.1016/S0140-6736(04)15793-0.PubMedCrossRef Bion JF, Heffner JE: Challenges in the care of the acutely ill. Lancet. 2004, 363: 970-977. 10.1016/S0140-6736(04)15793-0.PubMedCrossRef
74.
go back to reference Crane VS: New perspectives on preventing medication errors and adverse drug events. Am J Health Syst Pharm. 2000, 57: 690-697.PubMed Crane VS: New perspectives on preventing medication errors and adverse drug events. Am J Health Syst Pharm. 2000, 57: 690-697.PubMed
75.
go back to reference Barach P, Small SD: Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000, 320: 759-763. 10.1136/bmj.320.7237.759.PubMedPubMedCentralCrossRef Barach P, Small SD: Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000, 320: 759-763. 10.1136/bmj.320.7237.759.PubMedPubMedCentralCrossRef
76.
go back to reference Stelfox HT, Bates DW, Redelmeier DA: Safety of patients isolated for infection control. JAMA. 2003, 290: 1899-1905. 10.1001/jama.290.14.1899.PubMedCrossRef Stelfox HT, Bates DW, Redelmeier DA: Safety of patients isolated for infection control. JAMA. 2003, 290: 1899-1905. 10.1001/jama.290.14.1899.PubMedCrossRef
77.
go back to reference ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993, 50: 305-314. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993, 50: 305-314.
79.
go back to reference Herout PM, Erstad BL: Medication errors involving continuously infused medications in a surgical intensive care unit. Crit Care Med. 2004, 32: 428-432. 10.1097/01.CCM.0000108876.12846.B7.PubMedCrossRef Herout PM, Erstad BL: Medication errors involving continuously infused medications in a surgical intensive care unit. Crit Care Med. 2004, 32: 428-432. 10.1097/01.CCM.0000108876.12846.B7.PubMedCrossRef
80.
go back to reference Stambouly JJ, McLaughlin LL, Mandel FS, Boxer RA: Complications of care in a pediatric intensive care unit: a prospective study. Intensive Care Med. 1996, 22: 1098-1104. 10.1007/BF01699236.PubMedCrossRef Stambouly JJ, McLaughlin LL, Mandel FS, Boxer RA: Complications of care in a pediatric intensive care unit: a prospective study. Intensive Care Med. 1996, 22: 1098-1104. 10.1007/BF01699236.PubMedCrossRef
81.
go back to reference Donchin Y, Seagull FJ: The hostile environment of the intensive care unit. Curr Opin Crit Care. 2002, 8: 316-320. 10.1097/00075198-200208000-00008.PubMedCrossRef Donchin Y, Seagull FJ: The hostile environment of the intensive care unit. Curr Opin Crit Care. 2002, 8: 316-320. 10.1097/00075198-200208000-00008.PubMedCrossRef
82.
go back to reference Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, Lipsett PA, Bass E: Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999, 281: 1310-1317. 10.1001/jama.281.14.1310.PubMedCrossRef Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, Lipsett PA, Bass E: Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999, 281: 1310-1317. 10.1001/jama.281.14.1310.PubMedCrossRef
83.
go back to reference Bria WF, Shabot MM: The electronic medical record, safety, and critical care. Crit Care Clin. 2005, 21: 55-79. 10.1016/j.ccc.2004.08.001. viiiPubMedCrossRef Bria WF, Shabot MM: The electronic medical record, safety, and critical care. Crit Care Clin. 2005, 21: 55-79. 10.1016/j.ccc.2004.08.001. viiiPubMedCrossRef
84.
go back to reference Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991, 324: 370-376.PubMedCrossRef Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991, 324: 370-376.PubMedCrossRef
Metadata
Title
Clinical review: Medication errors in critical care
Authors
Eric Moyen
Eric Camiré
Henry Thomas Stelfox
Publication date
01-04-2008
Publisher
BioMed Central
Published in
Critical Care / Issue 2/2008
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/cc6813

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