Frequency and determinants of drug administration errors in the intensive care unit

Adverse drug event reporting in intensive care units: a survey of current practices

BACKGROUND

With the incidence of adverse drug events (ADEs) and adverse drug reactions (ADRs) higher in the intensive care unit (ICU) than other areas of the hospital, it is suspected that ADE/ADR surveillance systems differ between ICU and non-ICU areas. However, there is a lack of information about ADE/ADR identification, reporting, and evaluation strategies in the ICU. Understanding the frequency with which institutions incorporate standardized operational ADE/ADR definitions, triggers, and evaluation tools in this population will facilitate benchmarking between hospitals.

OBJECTIVE

To determine whether ADE/ADR identification, reporting, and evaluation strategies differ between ICU and non-ICU populations and to characterize ADE/ADR reporting strategies in the ICU.

METHODS

A validated survey was mailed to pharmacy directors at 590 randomly selected hospitals in the US having at least one ICU. A reminder was sent one week after the surveys were mailed. Five weeks later, a second survey was mailed to hospitals that did not respond.

RESULTS

The response rate was 22% (132/590); institutions were predominantly community (68.2%), with 199 or fewer (54.5%) operational beds and 19 or fewer (60.6%) ICU beds. ICU types included mixed medical/surgical (62.1%), medical (48.5%), surgical (31.8%), coronary (29.5%), neonatal (22.7%), and cardiothoracic (15.2%). Operational definitions for ADEs and ADRs varied little between ICU and non-ICU areas, as 92.4% of institutions used the same term for both settings. Triggers were used to identify ADE/ADRs hospital-wide (75%) and were usually the same between ICU and non-ICU areas (88.6%). ADE reporting was nearly always voluntary (94.7%), using paper reports (88.6%), phone calls (22.7%), e-mail (12.1%), Intranet (12.1%), Web-based/Internet (10.6%), or PDA (1.5%). Only 22% of hospitals tracked ICU-specific data.

CONCLUSIONS

ADE identification, reporting, and evaluation strategies are similar between ICU and non-ICU areas. Few institutions currently track ICU-specific ADE/ADR data. The institution of ICU-specific ADE detection and prevention strategies may improve the safety of critically ill patients.

Principles and practices of medication safety in the ICU

Medication errors are a significant public health problem in United States hospitals. Patients in the ICU are at particular risk for medication errors because of the characteristics of an ICU and the nature of its patients. This article reviews the principles of medication safety and applies these principles to the ICU, and suggests safe practices to improve medication safety in the ICU.

Conseqüências dos erros de medicação em unidades de terapia intensiva e semi-intensiva

O estudo objetivou caracterizar erros de medicação e avaliar conseqüências na gravidade dos pacientes e carga de trabalho de enfermagem em duas Unidades de Terapia Intensiva (UTI) e duas Semi-Intensiva (USI) de duas instituições hospitalares do município de São Paulo. A amostra foi constituída por 50 pacientes e os dados obtidos por meio do registro de ocorrências e prontuários, retrospectivamente. A gravidade e carga de trabalho de enfermagem foram avaliadas antes e após o erro. Do total de 52 erros, 12 (23,08%) ocorreram por omissão de dose, 11 (21,15%) e 9 (17,31%) por medicamento e dose erradas, respectivamente. Não houve mudança na gravidade dos pacientes (p=0,316), porém houve aumento na carga de trabalho de enfermagem (p=0,009). Quanto ao grupo de medicamentos envolvidos, potencialmente perigosos e não potencialmente perigosos, não houve diferenças estatisticamente significantes na gravidade (p=0,456) e na carga de trabalho de enfermagem (p=0,264), após o erro de medicação.

Disclosing errors and adverse events in the intensive care unit*

OBJECTIVE

To review the issue of disclosing errors in care and adverse events that have caused harm to patients in critical care.

DESIGN

Review the scope of the problem, the definitions of errors and adverse events, and the benefits and problems of disclosing errors and adverse events and provide an approach by which to have these difficult discussions.

SETTING

Medical center.

PATIENTS

Critically ill patients and their families.

INTERVENTIONS

Applying a systematic framework for disclosing errors and adverse events to affected patients and their families.

MEASUREMENTS AND MAIN RESULTS

Several national organizations mandate that physicians discuss errors in care and adverse events that have caused harm with affected patients, but failure to do so is a common problem in critical care as surveys of intensivists indicate that, although most believe that errors should be disclosed, few routinely do so. The likelihood of an adverse event is increased in intensive care units because of the nature of critical care. Not all errors or adverse events require disclosure. There are ethical, financial, legal, systems, and personal benefits to disclosing errors, and disclosure discussions should address common patient concerns.

CONCLUSIONS

Failure to disclose errors and adverse events in critical care is an important and common problem. There are numerous reasons why errors and adverse events should be disclosed, and use of a standard framework for doing so will facilitate the process.

Quality improvement of oral medication administration in patients with enteral feeding tubes

BACKGROUND

The correct administration of oral drugs to patients on enteral tube feeding presents a special challenge. As patients are usually unable to swallow oral drugs and many drugs should not be crushed, ways have to be found to administer them through the feeding tube. Measures to improve the quality of oral drug administration in patients with enteral feeding tubes may consist of introducing guidelines, training nurses, or giving patient-tailored advice by the pharmacy. An integrated program comprising all these measures is likely to result in the greatest improvements.

METHODS

A study was undertaken in two Dutch hospitals to investigate the effect of such an integrated program.

RESULTS

The integrated program in hospital I resulted in a decrease in the number of tube obstructions (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.047 to 1.05). There was a significant decrease in the number of administration errors per nurse in hospital II (OR 0.003, 95% CI 0.0005 to 0.02).

CONCLUSIONS

This multidisciplinary program comprising several interventions to promote the correct administration of drugs through an enteral feeding tube results in substantial improvements. As errors concerning administration of drugs to patients with enteral feeding tubes may lead to adverse drug events and loss of effect, these improvements are likely to contribute to a decrease in patient morbidity.

Medication errors and adverse drug events in an intensive care unit: Direct observation approach for detection

OBJECTIVE

To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence.

DESIGN

Prospective, direct observation study.

SETTING

Tertiary care academic medical center.

PATIENTS

Patients in a medical/surgical intensive care unit.

INTERVENTIONS

Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort.

MEASUREMENTS AND MAIN RESULTS

The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%).

CONCLUSIONS

Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.

Effects of Critical Care Nurses’ Work Hours on Vigilance and Patients’ Safety

• Background To minimize the occurrence of adverse events among patients, critical care nurses must be alert to subtle changes in patients’ conditions, perform accurate clinical assessments, and respond expediently. However, little is known about the effects of the nurses’ work hours on vigilance and patients’ safety.

• Objectives To describe the work patterns of critical care nurses, determine if an association exists between the occurrence of errors and the hours worked by the nurses, and explore whether these work hours have adverse effects on the nurses’ vigilance.

• Methods Data were obtained from a random sample of critical care nurses in the United States. Nurses eligible for the study were mailed two 14-day logbooks to fill out. Information collected included the hours worked, the time of day worked, overtime hours, days off, and sleep-wake patterns. On days worked, the respondents completed all work-related questions and questions about difficulties in remaining awake while on duty. Space was provided for descriptions of any errors or near errors that might have occurred. On days off, the nurses completed only those questions about sleep-wake patterns, mood, and caffeine intake.

• Results The 502 respondents consistently worked longer than scheduled and for extended periods. Longer work duration increased the risk of errors and near errors and decreased nurses’ vigilance.

• Conclusions The findings support the Institute of Medicine recommendations to minimize the use of 12-hour shifts and to limit nurses’ work hours to no more than 12 consecutive hours during a 24-hour period.

The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care

OBJECTIVE

Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting.

DESIGN

We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures.

SETTING

Academic, tertiary-care urban hospital.

PATIENTS

Medical intensive care unit and coronary care unit patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events as well as 223 serious errors. The rates per 1000 patient-days for all adverse events, preventable adverse events, and serious errors were 80.5, 36.2, and 149.7, respectively. Among adverse events, 13% (16/120) were life-threatening or fatal; and among serious errors, 11% (24/223) were potentially life-threatening. Most serious medical errors occurred during the ordering or execution of treatments, especially medications (61%; 170/277). Performance level failures were most commonly slips and lapses (53%; 148/277), rather than rule-based or knowledge-based mistakes.

CONCLUSIONS

Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening. Although many types of errors were identified, failure to carry out intended treatment correctly was the leading category.

Drug administration errors and their determinants in pediatric in-patients

OBJECTIVE

. To quantify the type and frequency of drug administration errors to pediatric in-patients and to identify associated factors.

DESIGN

Prospective direct-observation study of drug administration errors from April 2002 to March 2003.

SETTING

Four clinical units in a pediatric teaching hospital.

STUDY PARTICIPANTS

Twelve observers accompanied nurses giving medications and witnessed the preparation and administration of all drugs to all patients on all weekday mornings.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Discrepancies between physicians' orders and actual drug administration.

RESULTS

During the 1719 observed administrations to 336 patients by 485 nurses, 538 administration errors were detected, involving timing (36%), route (19%), dosage (15%), unordered drug (10%), or form (8% form). These errors occurred for 467 (27%) of the 1719 administrations. Intravenous drugs (OR = 0.28; CI = 0.16-0.49; versus miscellaneous) were associated with fewer errors. Error rates were higher for cardiovascular (OR = 3.38; CI = 1.24-9.27; versus miscellaneous) and central nervous system drugs (OR = 2.65; CI = 1.06-6.59; versus miscellaneous); unspecified dispensing system (OR = 2.06; CI = 1.29-3.29; versus store in the unit); non-intravenous non-oral administration (OR = 4.44; CI = 1.81-10.88; versus oral administration); preparation by the pharmacy (OR = 1.66; CI = 1.10-2.51); and administration by a hospital pool nurse, temporary staffing agency nurse, or nurse intern (OR = 1.67; CI = 1.04-2.68; versus registered full-time nurse). Each additional management procedure in the patient increased the risk of error (OR = 1.22; CI = 1.01-1.48).

CONCLUSIONS

The risk factors identified in our study should prove useful for designing preventive strategies, thereby improving the quality of care.

A controlled trial of smart infusion pumps to improve medication safety in critically ill patients

OBJECTIVE

Intravenous medications are vital during inpatient management. Errors associated with the administration of medications through intravenous infusion pumps to critically ill patients can result in adverse drug events. We sought to assess the impact of smart pumps with integrated decision support software on the incidence and nature of medication errors and adverse drug events.

DESIGN

We performed a prospective, randomized time-series trial and compared the serious medication error rate between intervention (decision support on) and control (decision support off) periods. Serious medication errors included both near-misses and preventable adverse drug events. Pump software produced log reports to help identify potential events. Events were presented to physicians for rating of event type, preventability, and severity.

SETTING

Cardiac surgical intensive care and step-down units between February and December 2002.

PATIENTS

Pump data were available for 744 cardiac surgery admissions.

INTERVENTIONS

Decision support during medication administration provided feedback including alerts, reminders, and unit-specific drug rate limits.

MEASUREMENTS AND MAIN RESULTS

We found a total of 180 serious medication errors, including 14 and 11 preventable adverse drug events and 73 and 82 nonintercepted potential adverse drug events in the control and intervention periods, respectively. The serious medication error rates in the control and intervention periods were 2.03 and 2.41 per 100 patient-pump-days, respectively (p = .124). We also found numerous opportunities for safety improvement. Violations of infusion practice during the intervention periods included 571 (25%) bypasses of the drug library. Medications were also frequently administered without documentation of physician orders in both periods (n = 823; 7.7%).

CONCLUSION

Intravenous medication errors and adverse drug events were frequent and could be detected using smart pumps. We found no measurable impact on the serious medication error rate, likely in part due to poor compliance. Although smart pumps have great promise, technological and nursing behavioral factors must be addressed if these pumps are to achieve their potential for improving medication safety.

Protocol-driven vs. physician-driven electrolyte replacement in adult critically ill patients

BACKGROUND

The intensive care unit is a dynamic environment, where high numbers of patients cared for by health care workers of different experiences and backgrounds might result in great variability in patient care. Protocol-driven interventions may facilitate timely and uniform care of common problems, like electrolyte disturbances. We prospectively compared protocol-driven (PRD) vs. physician-driven (PHD) electrolyte replacement in adult critically ill patients.

PATIENTS AND METHODS

In the first month of the two-month study, potassium, magnesium, and phosphate levels were checked by a physician before ordering replacement (PHD replacement period). Over the second month, ICU nurses proceeded with replacement according to the protocol (PRD replacement period). We collected demographic data, admission diagnosis, number of potassium, magnesium, and phosphate levels done per day, number of low levels per day, number of replacements per day, time between availability of results to ordering replacement, time to starting replacement, post-replacement levels, serum creatinine, replacement dose, arrhythmias and replacement route.

RESULTS

During the PHD replacement period, 43 patients meeting the inclusion criteria were admitted to the ICU, while 44 were admitted during the PRD month. The mean time (minutes) from identifying results to replacement of potassium, phosphate and magnesium was significantly longer with PHD replacement compared with PRD replacement (161, 187, and 189 minutes vs. 19, 26, and 19 minutes) (P<0.0001). The number of replacements needed and not given was also significantly lower in the PRD replacement period compared with the PHD replacement period (2, 4, and 0 compared with 9, 6 and 0) (P<0.05). No patients had high post-replacement serum concentrations of potassium, phosphate or magnesium.

CONCLUSIONS

This study shows that a protocol-driven replacement strategy for potassium, magnesium and phosphate is more efficient and as safe as a physician-driven replacement strategy.

Medication errors in anaesthesia and critical care

There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers. However, study of medication error is hampered by difficulty with definitions, research methods and study populations. Few doctors are as involved in the process of prescribing, selecting, preparing and giving drugs as anaesthetists, whether their practice is based in the operating theatre, critical care or pain management. Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. New technology, theories of human error and lessons learnt from the nuclear, petrochemical and aviation industries are being used to tackle the problem.

Prevention of medication errors

Medication error is the most frequent source of medical error that is associated with adverse events, and, in many cases, is preventable. Medication errors can occur at any step in the medication process. Medication error prevention and reduction begins with a systematic approach to their detection. An important approach to mitigating errors involves the reduction of variation in task performance using tested techniques and technologies from other industries. The most important component of error prevention and reduction is the proactive promotion of a safety culture by organizational leadership, with sustained education and support for users.

Medication safety and transfusion errors in the ICU and beyond

The modern day intensive care unit (ICU) is a place in which patients can receive continuous monitoring of physiologic variables with concentrated patient observation and care. Despite the "intensive care," errors do occur. This article reviews medication and transfusion errors, including the different types, causes, and possible solutions to prevent these errors from occurring in ICUs and the hospital at large.

Influence of Computerised Medication Charts on Medication Errors in a Hospital

INTRODUCTION

In hospitals where computerised physician order entry systems will not be available in the near future, there is a need to explore other ways of reducing medication errors that occur in the drug ordering and delivery system. One of these ways is the use of a computerised medication chart that is updated daily. The aim of this study was to evaluate the frequency, types and potential clinical significance of drug prescription and administration errors by comparing a traditional medication distribution system (where the transcription of handwritten into printed medication orders takes 3-5 days and the transfer of medication orders was not complete) with the use of a computerised medication chart (which was updated daily by pharmacy assistants on the ward).

METHODS

Data were collected during two 3-week periods, from a 32-bed internal medicine unit, before and after the introduction of the computerised medication charts. Prescribing errors were observed by evaluation of all new and changed medication orders and administration errors were detected by using the disguised-observation technique.

RESULTS

For prescribing errors, a total of 611 prescriptions before and 598 prescriptions after the intervention were evaluated. The total prescription error rate (of medication orders with >or=1 error) was found to be significantly higher with the computerised charts when compared with the old system (50.0% [299 of 598] vs 20.3% [124 of 611], odds ratio [OR] 3.80 [95% CI 2.94, 4.90]). This increase was caused by an increase in administrative prescription errors with a low potential clinical significance (mainly omission of the prescriber's name and the prescription date). The error rate for errors with a potential clinical significance was found to be significantly lower because the prescription error 'duplicate therapy' was eliminated (3.4% with the traditional medication chart vs 0% with the computerised chart). For administration errors, a total of 1122 drugs before the intervention and 1175 drugs after the intervention was observed to be administered. The total administration error rate was found to be significantly lower after the intervention (6.1% [72 of 1175] vs 10.5% [118 of 1122], OR 0.61 [95% CI 0.45, 0.84]), as was the error rate with a potential clinical significance. The contribution of handwritten medication orders to the total amount of medication orders was significantly decreased after the intervention (12.8% vs 20.6% [95% CI 4.6, 11.0]) and the administration of a drug ordered by a handwritten medication order resulted in a significantly higher administration rate than with administration of a drug ordered by a printed medication order (before the intervention 20.7% vs 8.0%, OR 2.99 [95% CI 1.96, 4.56], after the intervention 11.4% vs 5.6%, OR 2.18 [95% CI 1.16, 4.11]).

CONCLUSION

This observational study shows a significant reduction in clinically relevant, administration and (therapeutic) prescription error rates when applying a system using computerised and daily updated medication charts compared with a system using traditional medication charts. Therefore, the use of computerised and daily updated medication charts has the potential to improve the quality of the medication distribution process in hospitals waiting for the implementation of a computerised physician order entry system.

Proyecto de implantación del sistema de distribución de medicamentos en dosis unitarias en una unidad de cuidados intensivos

OBJECTIVE

To describe the implementation of a unitary dose drug dispensation system (UDDDS) with computerized medical orders in an intensive care unit (ICU) including 10 multi-purpose offices, and to obtain a medication error index as an indicator of the process quality.

METHOD

A UDDDS with computerized medical orders for intensive care was defined. By consensus among nurses, intensivists and pharmacists, the administration of high-risk drugs by perfusion or through a gastric tube was protocolized, and computerized medical orders were adapted to ICU dynamics, with both fluid therapy and enteral and parenteral nutrition becoming fully integrated. A prospective observational 8-month study with 15 cross-sectional time points was performed to estimate the overall error index and mean error per drug use process stage. The error index is estimated by dividing the number of errors into error opportunities, and is expressed as a percentage.

RESULTS

Computerized medical orders favored compliance with consensus protocols defined in software programs at the pharmacy department, even though the degree of adhesion degree was not quantitized. They also allowed a validation of all medical prescriptions by a pharmacist before dispensation. The total number of errors detected during the study period was 86. Error opportunities were 26,695, and the overall error index was 0.32%. During the study an error occurred every 312.5 error opportunities.

Dosing Practices and Risk Factors for Bleeding in Patients Receiving Enoxaparin for the Treatment of an Acute Coronary Syndrome

OBJECTIVES

To describe dosing practices and to identify risk factors for bleeding in patients with an acute coronary syndrome (ACS) who received treatment with enoxaparin.

DESIGN

Retrospective chart review.

SETTING

Coronary care unit of a tertiary-care teaching hospital.

PATIENTS

Patients with a discharge diagnosis of an ACS who received at least one dose of enoxaparin, 1 mg/kg, were eligible for this study. Enoxaparin dosing practices, factors that might influence the safety of enoxaparin administration, and bleeding events were documented. Multivariable regression analysis was used to identify independent predictors of bleeding in this clinical setting.

RESULTS

Of 208 patients with an ACS who received enoxaparin, 48 patients (23%) received a dose that was > 10% or < 10% of the recommended 1 mg/kg dose, 18 patients (9%) did not have body weight documentation to guide enoxaparin dosing, and 17 patients (8%) had significant renal impairment (serum creatinine > 150 micromol/L), with the potential for bioaccumulation of enoxaparin. There were 35 bleeding events (17%), of which 8 events (4%) were major. Risk factors for any bleeding (major or minor) were increasing patient age (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.13 to 2.20), coadministered nonsteroidal anti-inflammatory or antiplatelet drug therapy (OR, 2.38; 95% CI, 1.06 to 5.38), and number of enoxaparin doses (OR, 2.15; 95% CI, 1.25 to 3.68). Risk factors for major bleeding were increasing patient age (OR, 2.56; 95% CI, 1.05 to 6.28) and coadministered clopidogrel (OR, 7.70; 95% CI, 1.16 to 51.9).

CONCLUSION

In this clinical practice assessment of patients with an ACS, the use of enoxaparin was suboptimal, with the potential to increase bleeding complications. Coadministered clopidogrel, other drugs that affect hemostasis, and increasing age conferred an increased bleeding risk.

Dexmedetomidine Overdose in the Perioperative Setting

OBJECTIVE

To report 3 cases of accidental dexmedetomidine overdose in the perioperative setting and review the pathophysiology of α2-agonist overdose.

CASE SUMMARIES

Three patients accidentally received overdoses of dexmedetomidine, one intraoperatively (192 μg over 20 min) and 2 postoperatively (4 and 2 rather than 0.4 and 0.2 μg/kg/h; 0.5 μg/kg/min rather than 0.5 μg/kg/h). Hemodynamic parameters remained stable for all 3 patients. The most notable sign was oversedation diagnosed either clinically or using a bispectral index monitor; Naranjo criteria suggest possible or probable association of the reactions with dexmedetomidine. In all 3 cases, oversedation resolved within one hour of drug discontinuation. There were no other sequelae, and the remainder of each patient's hospital course was unremarkable.

DISCUSSION

As of this writing, dexmedetomidine dosing in excess of the label recommendation has been reported, but accidental dexmedetomidine overdose in clinical practice has not been described. Excessive levels of sedation were the only significant finding in all 3 patients. Dexmedetomidine's short redistribution half-life of 6 minutes should lead to rapid resolution of oversedation induced by overdoses if the overall duration of infusion is short (≤8 h). While the patients reported here were hemodynamically stable, dexmedetomidine may engender significant hemodynamic changes either because of sympatholysis at normal doses or vasoconstriction at higher than recommended doses. The absence of a significant hypertensive response to high dexmedetomidine concentrations suggests that dexmedetomidine-induced hypertension may be multifactorial, not simply related to plasma drug concentrations.

CONCLUSIONS

Practitioners presented with dexmedetomidine overdose should be prepared to manage oversedation. While hemodynamic alterations may be seen with dexmedetomidine use, hypertension from high dexmedetomidine plasma concentrations is not a consistent response. Practitioners using dexmedetomidine should carefully note that dosing for this agent is described by the manufacturer in μg/kg/h, not μg/kg/min.

What do we know about medication errors in inpatient psychiatry?

BACKGROUND

Adverse drug events (ADEs) have been implicated as a cause of substantial morbidity and mortality. Psychiatrists have successfully characterized one category of ADE--adverse drug reactions (ADRs), which have been studied from a medication-specific psychopharmacology frame of reference. The literature on ADEs, both preventable and nonpreventable, was reviewed within the broader patient safety framework.

METHODS

English-language studies involving ADEs and medication errors in psychiatry for 1996 through 2003 were identified on MEDLINE and by using a hand search of bibliographies.

RESULTS

Few reports on the incidence and characteristics of medication errors in psychiatric hospitals could be found. Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture. PREVENTION STRATEGIES: Application of a systems-oriented approach to ADE reduction and the promotion of a nonpunitive culture are essential. Clinical and pharmacy staff could monitor the literature for published reports of preventable adverse events and review those reports in multidisciplinary team meetings.

CONCLUSIONS

Psychiatry would benefit from learning about the terminology used in describing medication errors and ADEs. Relatively few data are available regarding the frequency and consequences of medication errors in psychiatry; more research is needed.