Medication Errors in PICU

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Pediatric ICU


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Medication Errors in PICU:

Medication Errors in PICU Resident in MUCH By Mahmoud Wahba


Contents Introduction Definitions Outcome Causes of medication errors Strategies to minimize errors


Introduction We are humans and therefore we will make mistakes. The culture has been shifting over the last decade to focus on how we can improve rather than blame each other for errors . This shift has led to success in many aspects of patient safety initiatives.

Children are particularly vulnerable to medication dosing errors:

Children are particularly vulnerable to medication dosing errors Children, particularly in pediatric intensive care , are at increased risk of medication errors. Children’s drug doses are calculated on an individual basis , related to age and weight and physician have to select from several concentrations of medications. Standardized prescriptions are therefore much less common than in the adult population


Pediatric elixirs often must be reconstituted from powder. Many intravenous medications are not available in pediatric unit-doses , so nurses need to calculate dilutions from adult unit-dose packages. Young children cannot talk about side effects , or note that the medicine dispensed in the hospital is not the same colour as the one they take at home

PICU and Medication errors:

PICU and Medication errors Critically ill children are prescribed twice as many medications as patients outside of the intensive care unit (ICU) Nearly all will suffer a potentially life-threatening error at some point during their stay .


Definitions Medical error The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Medication error Any error in the medication process, whether there are adverse consequences or not . Adverse drug event Any injury related to the use of a drug Not all adverse drug events are caused by medical error, nor do all medication errors result in an adverse drug event . Preventable adverse event Harm that could be avoided through event reasonable planning or proper execution of an action .


Near miss : The occurrence of an error that did not result in harm. Slip : A failure to execute an action due to a routine behavior being misdirected. Lapse : A failure to execute an action due to lapse in memory and a routine behavior being omitted. Mistake A knowledge-based error due to an incorrect thought process or analysis . Error of omission Failure to perform an appropriate action . Error of commission Performing an inappropriate action e.g. wrong drug ,wrong dose


Slips and lapses are skill-based behavior errors, when a routine behavior is misdirected or omitted . The person has the right idea but performs the wrong execution . For example, forgetting to restart an infusion of heparin postoperatively is a lapse . Restarting the heparin infusion but entering an incorrect infusion rate despite knowing the correct rate is a slip . Mistakes are knowledge-based errors (perception, judgment, inference, and interpretation) and occur due to incorrect thought processes or analyses. For example, prescribing heparin in a patient diagnosed with heparin-induced thrombocytopenia is a mistake.

Outcome of medication errors:

Outcome of medication errors Some medication errors may not result in in an obvious negative outcome e.g. a child who receives 10 times the amount of morphine due to error in infusion pump programming may appear unaffected if he is ventilated. We cannot measure if there has been any harm to this child from this overdose such as prolonged intubation and potentially ventilator acquired pneumonia, However, We do know he error has occurred and we can move toward preventing it from happening in the future


Other medication errors may result in more obvious harm e.g . wrong dose of Heparin can lead to cerebral hemorrhage. These errors are significant and usually result in hospital wife attention resulting in immediate system changes.


Impact on family and caregivers: Fracture personal and professional relationships ,and may lead to distrust of the healthcare system. Impact on economic picture of the healthcare as resources are utilized to address the outcome of such errors

The “5” highest areas for Errors:

The “5” highest areas for Errors Prescribing Transcribing Preparing Programming intravenous pumps Checking medications prior to administration


The earlier in the medication process an error occurs, the more likely it is to be intercepted Administration appears to be particularly vulnerable to error because of a paucity of system checks as most medications are administered by a single nurse . Nurses and pharmacists intercept up to 70% of prescription errors Preparation errors occur when there is a difference between the ordered amount or concentration of a medication and what is actually prepared and administered.


approximately two thirds of infusions prepared by nurses are outside industry-accepted standards and 6% contain a greater than twofold concentration error . Transcription errors are usually attributed to handwriting, abbreviation use, unit misinterpretation (‘mg’ for ‘mcg’), and mistakes in reading.


Incomplete prescription No signature No start date No dose No frequency No route Insufficient information No patient name No hospital number Drug sensitivity box not completed Illegible prescription Clinical decision error Need for drug Inappropriate choice of drug Duplication of therapy Inappropriate dose Inappropriate frequency Inappropriate route

Medication Error:

Medication Error Wrong: Patient Drug Dose Time Route

Our goal is that ……:

Our goal is that …… The correct patient gets the correct dose of the correct drug by the correct route at the correct time

Don’t forget :

Don’t forget The 1 st action while treating patients is …….. Do No Harm

How to prevent medication errors:

How to prevent medication errors The safest and most efficient means of improving patient safety is to improve the safety of the medication process. Strategies that have been shown to be successful include Medication standardization Computerized physician order entry (CPOE) Bar code technology Computerized intravenous infusion devices Medication reconciliation

Computerised physician order entry systems:

Computerised physician order entry systems CPOE targets the prescription and transcription stages of the medication process. The technology permits clinicians to enter orders directly into a computer workstation that is linked to a hospital clinical information system rather than on paper. Computerised physician order entry systems must have a pediatric weight based dosing calculator and weight specific maximum and minimum doses.


The main advantages of these systems track allergies recommend drug dosages provide adjustments for patients with altered renal or hepatic function identify potential drug-drug interactions


Major limitations for implementation include capital costs provider willingness to adopt the technology worries about technical malfunctions paradoxical increases in medication errors during implementation periods . there are less calculation errors but sometimes we push the wrong buttons


Two systematic reviews have documented that CPOE systems increase clinician adherence to guidelines and alerts, improve organizational efficiency, reduce costs, and even prevent medication errors , but there is limited evidence to support improved patient safety .


In this regard, CPOE technology highlights the important distinction between error and harm ; errors are an important intermediate outcome, but preventing patient harm is the ultimate goal . CPOE technology currently is not used in the majority of ICUs

Bar code technologies:

Bar code technologies Target the administration phase of the medication process. Used in conjunction with CPOE, bar code labels for the medication, the patient, and the provider administering the medication are scanned, reconciled, and documented electronically.


This process helps ensure that the correct patient gets the correct dose of the correct drug by the correct route at the correct time . Administration errors have been documented to be reduced by 60% .

Computerized intravenous infusion:

Computerized intravenous infusion Computerized intravenous infusion devices allow incorporation of CPOE and bar code technology for intravenous medications such that standardized concentrations, infusion rates, and dosing limits can be provided to help prevent intravenous medication errors .

Medication reconciliation:

Medication reconciliation ¾ patient medications are stopped on patient admission to the ICU . Many of these medications are not restarted by the time of patient discharge from the ICU or hospital Medication reconciliation is a process that matches a patient’s current hospital medication regimen against a patient’s long-term medication regimen. A coordinated medication reconciliation program can prevent drug withdrawal and ensure that life-saving medications are continued or restarted as soon as appropriate


Situational risk factors can divert providers’ attention and increase the risk of active failures. These need to be minimized. For example, acute and chronic sleep deprivation among residents has been shown to increase the risk of error Trainee supervision and graduated responsibility Clinical in experience can have a major impact on errors. 1st -year residents are five times more likely to make prescribing errors than those with more experience , as are residents at the start of new rotations .

Physicians, nurses, and pharmacists:

Physicians, nurses, and pharmacists Physicians, nurses, and pharmacists are integral to medication oversight and error interception. Participation of an intensivist in patient care in the ICU has been reported to decrease medication errors from 22% to 70% , complications by 50%


First , all intravenous medications should be prepared within the pharmacy department by pharmacists using a standardized process and standardized medication concentrations. Second , participation of a pharmacist in clinical rounds improves patient safety by reducing preventable ADEs PICU Satellite Pharmacy


Nurses Nurses play a particularly important role in patient safety because they are the health care providers with whom patients are likely to spend the greatest amount of time Double checking physician orders and pharmacy dispensing syringe labeling ensuring that the right drug in the right dose, with the right route of administration is given to the right patient at the right time.


2 important implications . One, decreasing nurse-to patient staffing ratios may be associated with an increased risk of medical errors . Nurse-to-patient ratios of 1:1 or 1:2 appear to be safest in the ICU . Second, nursing experience may have an important influence on patient safety. Experienced nurses are more likely to intercept errors compared with less experienced nurses

Three simple strategies to change medicine’s approach to medication errors have been proposed:

Three simple strategies to change medicine’s approach to medication errors have been proposed (a) recognize that current approaches for preventing medication errors are inadequate (b) improve the error-reporting system , avoid punishment , and focus on identifying performance improvement opportunities (c) understand and enhance human performance within the medication use process .

Error reporting:

Error reporting Error reporting should be voluntary, anonymous , centralized to increase the pool of data, and designed to identify opportunities for performance improvement. However, error reporting alone will not improve patient safety but rather is the first step in a continuous quality improvement cycle


We should focus on developing systems that view humans as fallible and assume that errors will occur , even in the best organizations.


Summary We are humans and therefore we will make mistakes Children, particularly in paediatric intensive care , are at increased risk of medication errors. medication errors may not result in in an obvious negative outcome and may lead to severe harm


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