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Patients in hospital intensive care units (ICUs) are being put at risk because of mistakes in administering injected drugs, research has found.
A study reported in the online British Medical Journal said that trainees were involved in most of these errors, as were workload, stress and fatigue.
The study monitored 113 ICUs around the world – 17 in the UK – over 24 hours and reported 861 errors affecting 441 patients. Twelve suffered permanent harm or death, of which eight cases involved trainees and were the result of 15 mistakes.
Mistakes occurred with many types of drugs, including insulin for diabetics, sedatives and blood-clotting drugs.
Of the total, the most frequent errors were wrong time of administration (386), missed medication (259), wrong dose (118), wrong drug (61) and wrong route (37).
Workload, stress and fatigue was reported by ICU staff as a contributing factor in 32% of all errors. Other factors included recently changed drug names (18%), written communications (14%), spoken communication (10%) and violation of standard protocols (9%).
The report says that the chances of mistakes happening significantly increase with the severity of the illness and whether the patient needs higher levels of care and drug administrations.
It concludes that organisational factors such as error-reporting systems and routine checks at shift changes can reduce the likelihood of such mistakes.
Copyright Press Association 2009
British Medical Journal online
