Medication Error Analysis: A Systematic Approach

Gourang   P.   Patel; Sandra   L.   Kane-Gill

Abstract

Medication errors are a common unfortunate occurrence in hospitals. One population that is particularly vulnerable are patients admitted to the Intensive Care Unit (ICU). ICU patients have a combination of rapidly changing medical conditions, laboratory values, and medications, which present a particular challenge for clinicians in practice in every aspect of patient care. Medication errors can occur in different phases (prescribing, distribution, administration, and monitoring) of the medication process and have a significant impact on morbidity and mortality. Medication error analysis requires a structured approach including: detection, reporting, and analysis, in order to provide the most efficient and practical information to the ICU team. In addition, a particular focus is made on the implementation of medication error prevention strategies such as evidenced-based protocols, team education, and technology. In an effort to reduce medication error rates in the ICU requires a collaborative, multi-disciplinary approach in order to be effective and consistent through time. Further research efforts are currently taking place in this challenging aspect of patient care to further provide more strategies for medication error detection, analysis, and prevention.

Keywords: Medication error, intensive care unit, root-cause analysis, prevention, multidisciplinary, patient safety

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