Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med. 2010;38:S83-S89. [PMID: 20502179 DOI: 10.1097/ccm.0b013e3181dd8364]

Emotional exhaustion and workload predict clinician-rated and objective patient safety

AIMS

To investigate the role of clinician burnout, demographic, and organizational characteristics in predicting subjective and objective indicators of patient safety.

BACKGROUND

Maintaining clinician health and ensuring safe patient care are important goals for hospitals. While these goals are not independent from each other, the interplay between clinician psychological health, demographic and organizational variables, and objective patient safety indicators is poorly understood. The present study addresses this gap.

METHOD

Participants were 1425 physicians and nurses working in intensive care. Regression analysis (multilevel) was used to investigate the effect of burnout as an indicator of psychological health, demographic (e.g., professional role and experience) and organizational (e.g., workload, predictability) characteristics on standardized mortality ratios, length of stay and clinician-rated patient safety.

RESULTS

Clinician-rated patient safety was associated with burnout, trainee status, and professional role. Mortality was predicted by emotional exhaustion. Length of stay was predicted by workload. Contrary to our expectations, burnout did not predict length of stay, and workload and predictability did not predict standardized mortality ratios.

CONCLUSION

At least in the short-term, clinicians seem to be able to maintain safety despite high workload and low predictability. Nevertheless, burnout poses a safety risk. Subjectively, burnt-out clinicians rated safety lower, and objectively, units with high emotional exhaustion had higher standardized mortality ratios. In summary, our results indicate that clinician psychological health and patient safety could be managed simultaneously. Further research needs to establish causal relationships between these variables and support to the development of managerial guidelines to ensure clinicians' psychological health and patients' safety.

Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review

BACKGROUND

There is a need to identify effective interventions to minimize the threat posed by medication administration errors (MAEs).

OBJECTIVE

Our objective was to review and critically appraise interventions designed to reduce MAEs in the hospital setting.

DATA SOURCES

Ten electronic databases were searched between 1985 and November 2013.

METHODS

Randomized controlled trials (RCTs) and controlled trials (CTs) reporting rates of MAEs or related adverse drug events between an intervention group and a comparator group were included. Data from each study were independently extracted and assessed for potential risk of bias by two authors. Risk ratios (RRs, with 95 % confidence intervals [CIs]) were used to examine the effect of an intervention.

RESULTS

Six RCTs and seven CTs were included. Types of interventions clustered around four main themes: medication use technology (n = 4); nurse education and training (n = 3); changing practice in anesthesia (n = 2); and ward system changes (n = 4). Reductions in MAE rates were reported by five studies; these included automated drug dispensing (RR 0.72, 95 % CI 0.53-1.00), computerized physician order entry (RR 0.51, 95 % 0.40-0.66), barcode-assisted medication administration with electronic administration records (RR 0.71, 95 % CI 0.53-0.95), nursing education/training using simulation (RR 0.17, 95 % CI 0.08-0.38), and clinical pharmacist-led training (RR 0.76, 95 % CI 0.67-0.87). Increased or equivocal outcome rates were found for the remaining studies. Weaknesses in the internal or external validity were apparent for most included studies.

LIMITATIONS

Theses and conference proceedings were excluded and data produced outside commercial publishing were not searched.

CONCLUSIONS

There is emerging evidence of the impact of specific interventions to reduce MAEs in hospitals, which warrant further investigation using rigorous and standardized study designs. Theory-driven efforts to understand the underlying causes of MAEs may lead to more effective interventions in the future.

A multicenter study of the point prevalence of drug-induced hypotension in the ICU

OBJECTIVE

To determine the point prevalence of drug-induced hypotension episodes in critically ill patients, to assess the episodes resulting from error, and to describe how episodes are treated.

DESIGN

Multicenter observational, 24-hour snapshot study.

SETTING

Forty-seven ICUs in 27 institutions located in the United States, Canada, and Singapore.

PATIENTS

A total of 688 ICU patients were evaluated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were included in the study if they had an episode of hypotension in the 24 hours prior to the clinical pharmacists' evaluation. The definition for a hypotensive episode is either a systolic blood pressure less than 90 mm Hg or a decrease in systolic blood pressure of 30 mm Hg over a 2-hour period. Each episode of unintentional hypotension was assessed for suspected drug-related causes. When a drug-related cause was suspected, an objective assessment tool, the modified Kramer, was used to determine causality. A score of at least "possible" was considered drug induced, referred to as a "drug-related hazardous condition." A drug-related hazardous condition is the temporal gap (intermediate stage) between the identification of an adverse drug reaction and the subsequent onset of drug-induced injury, known as an "adverse drug event." Drug-induced episodes were evaluated for medication errors and treatment. One hundred fifty-eight patients experienced 204 hypotensive episodes that were considered unintentional and drug related. Common drugs implicated included propofol, fentanyl, metoprolol, lorazepam, hydralazine, and furosemide. A total of 54 episodes (26.5%) resulted from medication errors. Common error types were improper dose/quantity (46%) and prescribing (25%). A total of 56.9% episodes were treated.

CONCLUSIONS

Many hypotensive episodes in the ICU are drug related and require treatment. A substantial portion of these episodes result from errors and are therefore preventable. This presents opportunities to improve prescribing including optimizing drug dosing to avoid possible patient harm from drug-induced hypotension.

Comparison of two databases to detect potential drug-drug interactions between prescriptions of HIV/AIDS patients in critical care

WHAT IS KNOWN AND OBJECTIVE

Adverse drug events (ADE), common and underestimated in ICU patients, have direct consequences on length of stay, mortality and hospital costs. Critically ill patients with HIV/AIDS are at a high risk of ADE because of their need for multiple drug therapies. ADE can be prevented, especially by the identification of potentially harmful drug-drug interactions (DDIs). Electronic databases are useful tools for the investigation of DDIs to avoid potential ADEs, thereby increasing patient safety. The purpose of this study was to compare the classification and severity rating of potential adverse drug interactions seen in the prescriptions for patients with HIV/AIDS in two databases, one with free access (Drugs.com(™)) and another requiring payment for access (Micromedex(®)).

METHODS

A cross-sectional retrospective study of the prescriptions issued for 40 ICU HIV/AIDS patients on mechanical ventilation, admitted for more than 48 h, in a referral hospital for infectious diseases in Rio de Janeiro, Brazil, was undertaken. One prescription was reviewed each week for each patient from the second day after admission. A list of all drug-drug interactions was generated for each patient using the two drug-drug interactions databases. The weighted kappa index was estimated to assess the agreement between the classifications of DDIs identified by both databases and qualitative assessment made of any discordant classification of recorded drug-drug interactions.

RESULTS AND DISCUSSION

Of the 106 prescriptions analysed, Micromedex(®) and Drugs.com identified 347 and 615 potential DDIs, respectively. A predominance of moderate interactions and pharmacokinetic interactions was observed. The agreement between the databases regarding the severity rating was only 68.3%. The weighted kappa of 0.44 is considered moderate. Better agreement (82.4%) was observed in the classification of mechanism of interaction, with a weighted kappa of 0.61.

WHAT IS NEW AND CONCLUSION

DDIs are common between the prescriptions of patients with HIV/AIDS admitted to the ICU. Although both databases were able to identify the clinically relevant DDIs, we observed a significant discrepancy in the classification of the severity of DDIs in the two bases. The free access database could serve as an alternative to the identification of DDIs in resource-limited settings; however, there is a need for better evidence-based assessments for your use on clinical management of more serious DDIs.

Overestimation of Glomerular Filtration Rate Among Critically Ill Adults With Hospital-Acquired Oligoanuric Acute Kidney Injury

BACKGROUND

Medication use in the intensive care unit (ICU) depends on creatinine-based glomerular filtration rate (GFR) estimates. Urine output deterioration may precede the creatinine rise resulting in delayed recognition of GFR reductions. Our objective was to quantify the disparity between estimated GFR (eGFR) and true GFR in ICU patients with hospital-acquired oligoanuric acute kidney injury (hAKI).

METHODS

This single-center cohort study examined adults who met the Acute Kidney Injury Network stage III urine output criterion ≥48 hours after ICU admission. True GFR was ≤15 mL/min/1.73 m(2), and eGFR was described by 6 different creatinine-based equations. True GFR and eGFR were compared on the day of hAKI diagnosis and followed for 4 days using multivariable linear regression with generalized estimating equations, adjusting for day and method.

RESULTS

Of the 691 patients screened, we enrolled 61 patients. After adjustment for multiple comparisons and day, there were significant differences in eGFR between the estimation methods and true GFR (P < .001). After day adjustment, eGFR overestimated true GFR by 17 to 50 mL/min/1.73 m(2) and overestimation persisted through the fourth day of hAKI (P ≤ .001).

CONCLUSION

Creatinine-based equations overestimated GFR in ICU patients with hAKI. This study highlights a population at risk of medication misadventures in whom systems optimization should be considered.

The cost of opioid-related adverse drug events

Opioids are the cornerstone of pain management; however, their use is associated with a variety of adverse drug events (ADEs) ranging from nausea and vomiting to urinary retention and respiratory depression. The purpose of this review is to describe the frequency and cost associated with different types of opioid-related ADEs to better understand their economic impact. A search of studies published in journals from 1946 to December, 2013, was conducted using MEDLINE and EMBASE. A total of 20 articles were reviewed. Data reflect a substantial economic burden of opioid-related ADEs resulting in high hospital costs, prolonged hospital stays, and substantial health care resource usage. Nausea, vomiting, and constipation are frequent and increased costs occur in all types of pain (surgical, nonsurgical, cancer, noncancer) in both inpatients and outpatients. Given the large economic burden of opioid-related ADEs, prevention rather than treatment may be the most effective strategy.

Management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration

PURPOSE

The management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration (CVVH) is reported.

SUMMARY

A 46-year-old African-American woman with New York Heart Association class IV, American College of Cardiology- American Heart Association stage D heart failure arrived from an outside facility with complaints of dyspnea after minimal exertion, orthopnea, and lower-extremity edema. A transthoracic echocardiogram revealed an estimated left ventricular ejection fraction of 15%. The patient subsequently required left ventricular assist device placement on hospital day 5 as a potential bridge to transplantation. A total digoxin loading dose of 500 μg i.v. (8.2 μg/kg) was given in two divided doses six hours apart. The next morning, the serum digoxin concentration was 1.9 ng/mL, and the patient was started on a maintenance digoxin dosage of 125 μg i.v. daily. On postoperative day (POD) 20, the patient developed acute kidney injury, and CVVH was initiated. The sieving coefficient (Sc), transmembrane clearance (CLtm), digoxin concentration in ultrafiltration fluid (Cuf), and need for supplemental digoxin were determined to account for CVVH- associated digoxin loss. After 14 days of CVVH, the patient's clinical condition improved, and CVVH was transitioned to intermittent hemodialysis. On POD 66, the patient was discharged to an extended-care facility without adverse reactions related to digoxin therapy.

CONCLUSION

Analysis of serum digoxin concentration and digoxin Cuf values suggested that digoxin was cleared by CVVH, allowed calculation of Sc and CLtm values, and facilitated determination of digoxin requirements in a critically ill patient requiring CVVH.

Short acting insulin analogues in intensive care unit patients

Blood glucose control in intensive care unit (ICU) patients, addressed to actively maintain blood glucose concentration within defined thresholds, is based on two major therapeutic interventions: to supply an adequate calories load and, when necessary, to continuously infuse insulin titrated to patients needs: intensive insulin therapy (IIT). Short acting insulin analogues (SAIA) have been synthesized to improve the chronic treatment of patients with diabetes but, because of the pharmacokinetic characteristics that include shorter on-set and off-set, they can be effectively used also in ICU patients and have the potential to be associated with a more limited risk of inducing episodes of iatrogenic hypoglycemia. Medical therapies carry an intrinsic risk for collateral effects; this can be more harmful in patients with unstable clinical conditions like ICU patients. To minimize these risks, the use of short acting drugs in ICU patients have gained a progressively larger room in ICU and now pharmaceutical companies and researchers design drugs dedicated to this subset of medical practice. In this article we report the rationale of using short acting drugs in ICU patients (i.e., sedation and treatment of arterial hypertension) and we also describe SAIA and their therapeutic use in ICU with the potential to minimize iatrogenic hypoglycemia related to IIT. The pharmacodynamic and pharmachokinetic characteristics of SAIA will be also discussed.

Factors associated with post-intensive care unit adverse events: a clinical validation study

BACKGROUND

Many patients discharged from intensive care units (ICU) have complex care needs, placing them at risk of an adverse event in a ward environment. Currently, there is limited understanding of factors associated with these events in the post-intensive care population. A recent study explored intensive care liaison nurses' opinions on factors associated with these events; 25 factors were identified, highlighting the multifaceted nature of post-intensive care adverse events.

AIM

This study aimed to clinically validate 25 factors intensive care liaison nurses believe are associated with post-intensive care adverse events, to determine the factors' relevance and importance to clinical practice.

DESIGN

Prospective, clinical validation study.

METHOD

Data were prospectively collected on a convenience sample of 52 patients at 4 tertiary referral hospitals in an Australian capital city. All patients had experienced an adverse event after intensive care discharge.

RESULTS

Each of the 25 factors contributed to adverse events in at least 6 patients. The factors associated with the most adverse events were those that related to the patient such as illness severity and co-morbidities.

CONCLUSION

Clinical care and research should focus on modifiable factors in care processes to reduce the risk of future adverse events in post-intensive care patients.

RELEVANCE TO CLINICAL PRACTICE

Many patients are at risk of post-ICU adverse events due to the contribution of non-modifiable factors. However, by focusing on modifiable factors in care processes, the risk of post-ICU adverse events may be reduced.

An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

Incident reporting is promoted as a key tool for improving patient safety in healthcare. We analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units each year in the North West of England between 2009 and 2012; 452 (20%) of these incidents led to harm to patients. Although 1461 (65%) incidents were judged to have been preventable, there was no reduction in the rate of incidents per 1000 days between 2009 and 2012 (5.9 in 2009, 6.6 in 2012). Furthermore, in the 2012 data, there were wide variations in the incident rates between units, the median (IQR [range]) rate per 1000 patient days for individual units being 6.8 (3.8-11.0 [1.3-37.1]). The variation in the percentage that could have been avoided was narrower, with a median (IQR [range]) of 70% (61-80% [38-100%]). The most commonly reported drugs were noradrenaline (161 incidents, 92 with harm), heparins (153 incidents, 29 with harm), morphine (131 incidents, 14 with harm) and insulin (111 incidents, 54 with harm). The administration of drugs was the stage in the process where incidents were most commonly reported; it was also the stage most likely to harm patients. We conclude that the wide range in reported rates between units, and the scope for preventing many incidents, suggest that quality improvement initiatives could improve medication safety in the units studied.

Implementing smart pump technology in a pediatric intensive care unit: a cost-effective approach

OBJECTIVE

To analyze the cost effectiveness of implementing smart infusion pump technology in a pediatric intensive care unit (PICU).

MATERIAL AND METHODS

An observational, prospective, intervention study with analytical components was carried out. A drug library was developed and integrated into the Carefusion Alaris Guardrails® infusion systems. A systematic analysis of all the data stored on the devices during use was performed by the data processing program Guardrails® CQI v4.1 Event Reporter. Intercepted errors were classified in terms of their potential severity and probability of causing an adverse effect (PAE) had they reached the patient. Knowing the estimated cost of a preventable adverse effect (AE), we analyzed costs saved and the profit/cost ratio resulting from the implementation process.

RESULTS

Compliance with the drug library was 92% and during the study period 92 infusion-related programming errors were intercepted, leading to a saving of 172,279 euros by preventing AEs. This means that 2.15 euros would be obtained for each euro invested in hiring a pharmacist to implement this technology.

DISCUSSION

The high percentage of use of safety software in our study compared to others allowed for the interception of 92 errors. The estimation of the potential impact of these errors is based on clinical judgment. The cost saved might be underestimated because the cost of an AE is usually higher in pediatrics, indirect and intangible costs were not considered and pharmacists involved do not spend the whole day on this task.

CONCLUSIONS

Smart pumps have shown to be profitable in a PICU because they have the ability to intercept potentially serious medication errors and reduce costs associated with such errors.

Medication Errors in the Intensive Care Unit

Medication errors in intensive care units put patients at risk for injury or death every day. Safety requires an organized and systematic approach to improving the tasks, technology, environment, and organizational culture associated with medication systems. The Systems Engineering Initiative for Patient Safety model can help leaders and health care providers understand the complicated and high-risk work associated with critical care. Using this model, the author combines a human factors approach with the well-known structure-process-outcome model of quality improvement to examine research literature. The literature review reveals that human factors, including stress, high workloads, knowledge deficits, and performance deficits, are associated with medication errors. Factors contributing to medication errors are frequent interruptions, communication problems, and poor fit of health information technology to the workflow of providers. Multifaceted medication safety interventions are needed so that human factors and system problems can be addressed simultaneously.

Prevention of adverse drug events and cost savings associated with PharmD interventions in an academic Level I trauma center: an evidence-based approach

BACKGROUND

The financial benefit of an established clinical pharmacy service in the trauma intensive care unit has not been well-described. This study was conducted to identify adverse drug events prevented by the clinical pharmacy team and to determine the net cost savings associated with their input on a multidisciplinary trauma service.

METHODS

Between July 2010 and June 2011, we conducted a retrospective analysis of clinical pharmacy activities and interventions on our 31-bed trauma unit managed by a multidisciplinary team. At the initiation of the study, a Web-based pharmacy documentation system was officially integrated into the trauma pharmacy work process. Based on this system, the type of intervention and a value of cost savings ($0-$6,000) were assigned to each activity. Cost-saving values for interventions were calculated from the literature describing the costs of adverse drug events and average drug costs.

RESULTS

Over the year, a total of 2,574 pharmacy activity entries were documented in the Quantifi system. The total conservative estimate of cost savings associated with clinical pharmacy interventions amounted to $565,664. Considering the mean US hospital pharmacist salary and the highest quoted cost associated with the Quantifi program, the net cost savings associated with our clinical pharmacist interventions on the trauma service was $428,327. Most of the interventions (53%) fell under the category of pharmacotherapy improvement, with 21% in the category of quality/safety improvement and 18% as antibiotic stewardship. Prevention of 34 serious adverse drug events was documented. Antibiotic changes and discontinuing medications were other common interventions. Antimicrobial medications (668), anticoagulants (270), and gastrointestinal medications (231) were the most common medication classes involved in pharmacy interventions.

CONCLUSION

Using a Web-based pharmacy documentation system, we were able to demonstrate prevention of serious adverse drug events and a significant cost savings by including clinical pharmacy in a multidisciplinary approach to caring for the seriously injured.

LEVEL OF EVIDENCE

Economic analysis, level III; therapeutic study, level IV.

Proactive clinical pharmacist interventions in critical care: effect of unit speciality and other factors

BACKGROUND

Clinical pharmacists working in critical-care areas have a beneficial effect on a range of medication-related therapies including improving medication safety, patient outcomes and reducing medicines' expenditure. However, there remains a lack of data on specific factors that affect the reason for and type of interventions made by clinical pharmacists, such as unit speciality.

OBJECTIVE

To compare the type of proactive medicines-related interventions made by clinical pharmacists on different critical-care units within the same institution.

METHODS

A retrospective evaluation of proactive clinical pharmacist recommendations, made in three separate critical-care areas. Intervention data were analysed over 18 months (general units) and 2 weeks for the cardiac and neurological units. Assessment of potential patient harm related to the medication interventions were made in the neurological and cardiac units.

KEY FINDINGS

Overall, 5623, 211 and 156 proactive recommendations were made; on average 2.2, 3.8 and 4.6 per patient from the general, neurological and cardiac units respectively. The recommendations acceptance rate by medical staff was approximately 90% for each unit. The median potential severity of patient harm averted by the interventions were 3.6 (3; 4.2) and 4 (3.2; 4.4) for the neurological and cardiac units (P = 0.059). The reasons for, types and drug classification of the medication recommendations demonstrated some significant differences between the units.

CONCLUSIONS

Clinical pharmacists with critical-care training make important medication recommendations across general and specialist critical-care units. The patient case mix and admitting speciality have some bearing on the types of medication interventions made. Moreover, severity of patient illness, scope of regular/routine specialist pharmacist service and support systems provided also probably affect the reason for these interventions.

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study

The objective was to compare the characteristics of medication errors reported to 2 national error reporting systems by conducting a cross-sectional analysis of errors reported from adult intensive care units to the UK National Reporting and Learning System and the US MedMarx system. Outcome measures were error types, severity of patient harm, stage of medication process, and involved medications. The authors analyzed 2837 UK error reports and 56 368 US reports. Differences were observed between UK and US errors for wrong dose (44% vs 29%), omitted dose (8.6% vs 27%), and stage of medication process (prescribing: 14% vs 49%; administration: 71% vs 42%). Moderate/severe harm or death was reported in 4.9% of UK versus 3.4% of US errors. Gentamicin was cited in 7.4% of the UK versus 0.7% of the US reports (odds ratio = 9.25). There were differences in the types of errors reported and the medications most often involved. These differences warrant further examination.

Adverse drug events during AKI and its recovery

BACKGROUND AND OBJECTIVES

The impact of AKI on adverse drug events and therapeutic failures and the medication errors leading to these events have not been well described.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A single-center observational study of 396 hospitalized patients with a minimum 0.5 mg/dl change in serum creatinine who were prescribed a nephrotoxic or renally eliminated medication was conducted. The population was stratified into two groups by the direction of their initial serum creatinine change: AKI and AKI recovery. Adverse drug events, potential adverse drug events, therapeutic failures, and potential therapeutic failures for 148 drugs and 46 outcomes were retrospectively measured. Events were classified for preventability and severity by expert adjudication. Multivariable analysis identified medication classes predisposing AKI patients to adverse drug events.

RESULTS

Forty-three percent of patients experienced a potential adverse drug event, adverse drug event, therapeutic failure, or potential therapeutic failure; 66% of study events were preventable. Failure to adjust for kidney function (63%) and use of nephrotoxic medications during AKI (28%) were the most common potential adverse drug events. Worsening AKI and hypotension were the most common preventable adverse drug events. Most adverse drug events were considered serious (63%) or life-threatening (31%), with one fatal adverse drug event. Among AKI patients, administration of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antibiotics, and antithrombotics was most strongly associated with the development of an adverse drug event or potential adverse drug event.

CONCLUSIONS

Adverse drug events and potential therapeutic failures are common and frequently severe in patients with AKI exposed to nephrotoxic or renally eliminated medications.

Evaluation of the effect of information integration in displays for ICU nurses on situation awareness and task completion time: A prospective randomized controlled study

OBJECTIVE

The study measured whether nurses' situation awareness would increase and task completion time decrease when they used an integrated information display compared to traditional displays for medication management, patient awareness and team communication.

SETTING

The Burn Trauma Intensive Care Unit (BTICU) at the University Hospital, University of Utah Health Science Center, Salt Lake City, Utah, USA.

PARTICIPANTS

12 experienced BTICU nurses.

MEASURES

Situation awareness (accuracy of the participants' answer) and task completion time (response time from seeing the question to submitting the answer) were measured using paper prototypes of both displays.

STUDY DESIGN

Counter-balanced (on display order), repeated-measures design.

MAIN RESULTS

Nurses had a higher situation awareness when using the integrated display, with an overall accuracy of 85.3% compared to 61.8% with the traditional displays (odds ratio 3.61, P<.001, 95% CI=2.34…5.57). Task completion times were nearly half with integrated displays compared to traditional displays (median 26.0 and 42.1s, hazard ratio 2.31, P<.001, CI=1.83…2.93).

CONCLUSIONS

An integrated ICU information display increased nurses' situation awareness and decreased task completion time. Information integration has the potential to decrease errors, increase nurses' productivity and may allow nurses to react faster to a patient's clinical needs. Bidirectional device communication is needed for these displays to achieve full potential in improving patient safety.

[Medication errors in Spanish intensive care units]

OBJECTIVE

To estimate the incidence of medication errors in Spanish intensive care units.

DESIGN

Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU.

SETTING

Spanish intensive care units.

PATIENTS

Patients admitted to the intensive care unit participating in the SYREC during the period of study.

MAIN VARIABLES OF INTEREST

Risk, individual risk, and rate of medication errors.

RESULTS

The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable".

CONCLUSIONS

Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable.

Interventions to reduce medication errors in adult intensive care: a systematic review

Critically ill patients need life saving treatments and are often exposed to medications requiring careful titration. The aim of this paper was to review systematically the research literature on the efficacy of interventions in reducing medication errors in intensive care. A search was conducted of PubMed, CINAHL EMBASE, Journals@Ovid, International Pharmaceutical Abstract Series via Ovid, ScienceDirect, Scopus, Web of Science, PsycInfo and The Cochrane Collaboration from inception to October 2011. Research studies involving delivery of an intervention in intensive care for adult patients with the aim of reducing medication errors were examined. Eight types of interventions were identified: computerized physician order entry (CPOE), changes in work schedules (CWS), intravenous systems (IS), modes of education (ME), medication reconciliation (MR), pharmacist involvement (PI), protocols and guidelines (PG) and support systems for clinical decision making (SSCD). Sixteen out of the 24 studies showed reduced medication error rates. Four intervention types demonstrated reduced medication errors post-intervention: CWS, ME, MR and PG. It is not possible to promote any interventions as positive models for reducing medication errors. Insufficient research was undertaken with any particular type of intervention, and there were concerns regarding the level of evidence and quality of research. Most studies involved single arm, before and after designs without a comparative control group. Future researchers should address gaps identified in single faceted interventions and gather data on multi-faceted interventions using high quality research designs. The findings demonstrate implications for policy makers and clinicians in adopting resource intensive processes and technologies, which offer little evidence to support their efficacy.

Medication errors and adverse drug events in kidney transplant recipients: incidence, risk factors, and clinical outcomes

STUDY OBJECTIVE

To determine the incidence, risk factors, and clinical outcomes associated with clinically significant medication errors or adverse drug events in kidney transplant recipients.

DESIGN

Retrospective observational study.

SETTING

Transplant center at an academic medical center.

PATIENTS

A total of 476 adults who received kidney transplants between June 2006 and July 2009.

MEASUREMENTS AND MAIN RESULTS

Severe or significant medication errors and adverse drug events (medication-related problems [MRPs]) were identified by medical record review. Only patient-induced medication errors (e.g., took wrong dose or frequency of drug, took drug not prescribed) were captured. Clinical outcomes included patient and graft survival, infections (including cytomegalovirus), readmissions, and acute rejection episodes. Thirty-seven (8%) of the 476 patients developed a clinically significant MRP. Univariate and confirmatory multivariate analyses revealed that female sex, African-American race, pretransplantation diabetes mellitus, delayed graft function, and retransplant recipients were independent risk factors for developing an MRP. Patients with MRPs had significantly higher rates of acute rejection (11% vs 30%, p=0.004), cytomegalovirus infection (15% vs 30%, p=0.033), and 30-day readmissions (5% vs 16%, p=0.018). Graft survival was also significantly lower in patients who had MRPs (p<0.001).

CONCLUSION

Patient-induced medication errors and associated adverse drug events were common in kidney transplant recipients. General and transplant-specific risk factors were associated with the development of these MRPs, and MRPs were associated with increased risk of rejection and graft loss.

Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit

PURPOSE

To establish the baseline prescribing error rate in a tertiary paediatric intensive care unit (PICU) and to determine the impact of a zero tolerance prescribing (ZTP) policy incorporating a dedicated prescribing area and daily feedback of prescribing errors.

METHODS

A prospective, non-blinded, observational study was undertaken in a 12-bed tertiary PICU over a period of 134 weeks. Baseline prescribing error data were collected on weekdays for all patients for a period of 32 weeks, following which the ZTP policy was introduced. Daily error feedback was introduced after a further 12 months. Errors were sub-classified as 'clinical', 'non-clinical' and 'infusion prescription' errors and the effects of interventions considered separately.

RESULTS

The baseline combined prescribing error rate was 892 (95 % confidence interval (CI) 765-1,019) errors per 1,000 PICU occupied bed days (OBDs), comprising 25.6 % clinical, 44 % non-clinical and 30.4 % infusion prescription errors. The combined interventions of ZTP plus daily error feedback were associated with a reduction in the combined prescribing error rate to 447 (95 % CI 389-504) errors per 1,000 OBDs (p < 0.0001), an absolute risk reduction of 44.5 % (95 % CI 40.8-48.0 %). Introduction of the ZTP policy was associated with a significant decrease in clinical and infusion prescription errors, while the introduction of daily error feedback was associated with a significant reduction in non-clinical prescribing errors.

CONCLUSION

The combined interventions of ZTP and daily error feedback were associated with a significant reduction in prescribing errors in the PICU, in line with Department of Health requirements of a 40 % reduction within 5 years.

Bench-to-bedside review: Rapid molecular diagnostics for bloodstream infection--a new frontier?

Among critically ill patients, the diagnosis of bloodstream infection poses a major challenge. Current standard bacterial identification based on blood culture platforms is intrinsically time-consuming and slow. The continuous evolvement of molecular techniques has the potential of providing a faster, more sensitive and direct identification of causative pathogens without prior need for cultivation. This may ultimately impact clinical decision-making and antimicrobial treatment. This review summarises the currently available technologies, their strengths and limitations and the obstacles that have to be overcome in order to develop a satisfactory bedside point-of-care diagnostic tool for detection of bloodstream infection.

Kidney failure related to broad-spectrum antibiotics in critically ill patients: secondary end point results from a 1200 patient randomised trial

OBJECTIVES

To explore whether a strategy of more intensive antibiotic therapy leads to emergence or prolongation of renal failure in intensive care patients.

DESIGN

Secondary analysis from a randomised antibiotic strategy trial (the Procalcitonin And Survival Study). The randomised arms were conserved from the primary trial for the main analysis.

SETTING

Nine mixed surgical/medical intensive care units across Denmark.

PARTICIPANTS

1200 adult intensive care patients, 18+ years, expected to stay +24 h.

EXCLUSION CRITERIA

bilirubin >40 mg/dl, triglycerides >1000 mg/dl, increased risk from blood sampling, pregnant/breast feeding and psychiatric patients.

INTERVENTIONS

Patients were randomised to guideline-based therapy ('standard-exposure' arm) or to guideline-based therapy supplemented with antibiotic escalation whenever procalcitonin increased on daily measurements ('high-exposure' arm).

MAIN OUTCOME MEASURES

Primary end point: estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2). Secondary end points: (1) delta eGFR after starting/stopping a drug and (2) RIFLE criterion Risk 'R', Injury 'I' and Failure 'F'. Analysis was by intention to treat.

RESULTS

28-day mortality was 31.8% and comparable (Jensen et al, Crit Care Med 2011). A total of 3672/7634 (48.1%) study days during follow-up in the high-exposure versus 3016/6949 (43.4%) in the 'standard-exposure arm were spent with eGFR <60 ml/min/1.73 m(2), p<0.001. In a multiple effects model, 3 piperacillin/tazobactam was identified as causing the lowest rate of renal recovery of all antibiotics used: 1.0 ml/min/1.73 m(2)/24 h while exposed to this drug (95% CI 0.7 to 1.3 ml/min/1.73 m(2)/24 h) vs meropenem: 2.9 ml/min/1.73 m(2)/24 h (2.5 to 3.3 ml/min/1.73 m(2)/24 h)); after discontinuing piperacillin/tazobactam, the renal recovery rate increased: 2.7 ml/min/1.73 m(2)/24 h (2.3 to 3.1 ml/min/1.73 m(2) /24 h)). eGFR <60 ml/min/1.73 m(2) in the two groups at entry and at last day of follow-up was 57% versus 55% and 41% versus 39%, respectively.

CONCLUSIONS

Piperacillin/tazobactam was identified as a cause of delayed renal recovery in critically ill patients. This nephrotoxicity was not observed when using other beta-lactam antibiotics.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00271752.

Medication errors reported in a pediatric intensive care unit for oncologic patients

BACKGROUND

Considering all sources of errors that may occur during healthcare, medication errors are the most common and also the most frequent cause of adverse events.

OBJECTIVE

The objective of the study was to describe the medication errors reported in a pediatric intensive care unit for oncologic patients.

METHODS

This is a descriptive and exploratory study. The errors were reported by the professionals involved in the medication system in a medication error report form developed for the study.

RESULTS

The sample consisted of 110 medication errors reported on 71 forms. The omission error was the most common error type reported (22.7%), followed by administration error (18.2%). No harm to patients was reported in 83.1% of the notifications.

CONCLUSION

The analysis of the110 medication errors provides evidence of the context of their occurrence and the need to implement measures that can prevent or intercept these errors.

IMPLICATIONS FOR PRACTICE

In an institution without adverse events report and a formal system to patient safety analysis, the implementation of a local nonpunitive approach to medication errors notification represented an important tool to patient safety promotion.

Adverse drug events in intensive care units: a cross-sectional study of prevalence and risk factors

BACKGROUND

Adverse drug events are considered determinants of patient safety and quality of care.

OBJECTIVE

To assess the characteristics of adverse drug events in patients admitted to an intensive care unit and determine the impact of severity of illness and nursing workload on the prevalence of the events.

METHODS

A cross-sectional survey based on retrospective analysis of a high-quality patient data management system for a university-based intensive care unit was used. The prevalence of adverse drug events was measured by using a validated global trigger tool adapted for the critical care environment. Severity was determined by using a validated algorithm. Disease severity and nursing workload were assessed by using validated scoring systems. An investigator blinded to the study and a panel of experts assessed putative serious adverse drug events for each drug taken. Characteristics of patients with and without adverse drug events were compared by using univariate and stepwise multivariate logistic regression.

RESULTS

During 175 of 1009 intensive care unit days screened, 230 adverse drug events occurred in 79 patients. The most common events were hypoglycemia, prolonged activated partial thromboplastin time, and hypokalemia. Of the adverse events, 96% were classified as causing temporary harm and 4% as causing complications. Both mean severity of disease and nursing workload were significantly higher on days when 1 or more adverse drug events occurred.

CONCLUSION

Adverse drug events were common in intensive care unit patients and were associated with illness severity and nursing workload.

The effect of therapeutic hypothermia on drug metabolism and response: cellular mechanisms to organ function

INTRODUCTION

Therapeutic hypothermia is being employed clinically due to its neuro-protective benefits. Both critical illness and therapeutic hypothermia significantly affect drug disposition, potentially contributing to drug-therapy and drug-disease interactions. Currently, there is limited information on the known alterations in drug concentration and response during mild hypothermia treatment, and there is a limited understanding of the specific mechanisms that underlie alterations in drug concentrations and the potential clinical importance of these changes.

AREAS COVERED

A systemic review of the effect of therapeutic hypothermia on drug metabolism, disposition and response is provided. Specifically, the clinical and preclinical evidence of the effects of therapeutic hypothermia on blood flow, specific hepatic metabolism pathways, transporter function, renal excretion, pharmacodynamics and the effects during rewarming are reviewed.

EXPERT OPINION

Available evidence demonstrates that mild hypothermia decreases the clearance of a variety of drugs with apparently little change in drug-protein binding. Recent evidence suggests that the magnitude of the change is elimination route specific. Further research is needed to determine the impact of these alterations on both drug concentration and response in order to optimize the therapeutic hypothermia in this vulnerable patient population.

Nursing implications for prevention of adverse drug events in the intensive care unit

Adverse drug events are common in the intensive care unit setting. Despite the existence of many long-standing safety principles (such as the "five rights") and new mechanisms to promote medication safety, there is still a gap between practice and the goal of patient safety. This is the result of the many human and system factors that impact care delivery. Research supports the role of the nurse as having a positive impact on patient outcomes. Future research requires the evaluation of new strategies and technologies to support safe medication administration. For example, patient simulation is being used to teach student and novice nurses principles of medication administration in a "safe" setting that more closely resembles the clinical environment. The Institute of Nursing repeatedly has stressed the need to address the organizational, technical, and human issues that impact patient safety, with an emphasis on the need to transform the nurse work environment to keep patients safe. This transformation will require a new level of interdisciplinary research and nursing involvement to address better care for our patients and, in particular, reduce adverse drug events.

Adverse drug reactions in hospital and ambulatory care settings identified using a large administrative database

BACKGROUND

Previous studies are limited in sample size and number of sites for the detection and characterization of adverse drug reactions (ADRs) in ambulatory care and hospital settings.

OBJECTIVE

To determine the prevalence and distribution of suspected ADRs according to demographic characteristics and drug classes for ambulatory care and hospitalized patients.

METHODS

A cross-sectional evaluation of administrative data from 2002-2005, containing a maximum of 20 million Medicare and commercially insured patients in a year, was completed. Individuals with one or more claims suggesting an ADR were identified, using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) criteria referred to as a "suspected ADR." Frequency of ICD-9-CM codes consistent with suspected ADRs for the 4 years was calculated for hospital and ambulatory care settings, based on age ranges, comorbidities, and drug classes.

RESULTS

Between 2002 and 2005, the average annual prevalence of suspected ADRs was 0.5%, with a total of 249,633 suspected ADRs during the 4 years. The mean age of hospitalized patients experiencing a suspected ADR was 12 years older than that of ambulatory care patients and 20 years older than that of the general database population. Diseases of the circulatory and endocrine/nutritional/metabolic systems rank among the top 5 comorbid conditions in hospitalized patients who had a suspected ADR. Injury and poisoning was the primary comorbidity in ambulatory patients. High-risk medications frequently associated with suspected ADRs in both settings were antineoplastic and anticoagulant agents. Other drug classes commonly associated with suspected ADRs in hospitalized patients were antihypertensives and diuretics. For the ambulatory care setting, drug classes frequently associated with suspected ADRs were antirheumatic and antiarteriosclerotic agents.

CONCLUSIONS

ADR detection, using administrative data, revealed differences in age, comorbidities, and drug classifications between ambulatory care and hospital settings. The results can be used to develop focused prevention strategies and targeted surveillance for individuals most at risk for developing ADRs.