Principles and practices of medication safety in the ICU

High alert medications off the radar: A systematic review

Objective

To identify new drugs that present an increased risk of causing significant damage to critically ill patients due to failure in the administration process.

Method

The systematic literature review was conducted in the PubMed, Lilacs, Scopus, Web of Science and gray literature. The year in which the study was conducted was not restricted.

Results

The initial search in the databases identified 1477 studies. Fifty manuscripts were selected for evaluation of the full text, at the end of which seven articles were included in this systematic review. As for the characteristic of medication errors, the highest frequency occurred in the administration and prescription phases. In all included studies, incidents with drugs that led to damage were observed. The drugs that are not included in the official lists as High Alert Medications (HAM) that presented an increased risk of causing damage due to medication errors found were: risperidone and piperacycline + tazobactan, in addition to the Infectious Agent class.

Conclusion

The results revealed that in fact there are drugs not listed as HAM that, when used in errors, promote greater risks of generating damage in critically ill patients. These described drugs should be considered for inclusion in future official lists of HAM.

The roles and patterns of critical care pharmacists: a literature review and practical operation model in China

Drug-related problems (DRPs) are prevalent in critically ill patients and may significantly increase mortality risks. The participation of critical care pharmacists (CCPs) in the medical team has demonstrated a benefit to healthcare quality. Research indicates that CCP medication order evaluations can reduce DRPs, while their participation in rounds can reduce adverse drug events and shorten hospital stays. Pharmacist medication reconciliation often proves more effective than physicians, and CCPs play a crucial role in antimicrobial management and reducing treatment costs. Despite these benefits, there is a noticeable lack of practical guidance for implementing CCP roles effectively. Their workflow heavily influences the efficiency of CCPs. Integrating results from the literature with our practical experience, we have detailed workflows and critical entry points that CCPs can refer to. Pharmacists should be proactive rather than passive consultants. Pre-round medication order evaluations are crucial for determining the depth of a pharmacist's involvement in patient care. These evaluations should cover the following aspects: medication indication, dosage, treatment duration, detection of DRPs, implementation of therapeutic drug monitoring, dosing of sedatives and analgesics, and pharmaceutical cost containment. Beyond identifying medication issues, a primary task during rounds is gathering additional information and building trust with the medical team. Post-round responsibilities for CCPs include patient and caregiver education on medication, medication reconciliation for transitioning patients, and follow-up care for post-ICU patients. Establishing a rationalized and standardized workflow is essential to minimize daily work omissions and maximize the pharmacist's value. A multidisciplinary pharmacist-led team can significantly promote the rational use of antibiotics. Participation in post-ICU outpatient follow-ups can reduce drug-induced injuries after discharge. This review provides a detailed overview of the tasks performed by CCPs before, during, and after medical rounds, serving as a valuable reference for establishing an efficient workflow for CCPs.

Factors influencing accuracy when preparing injectable drug concentrations in appliance with clinical practice: a norepinephrine case study

Errors in injectable preparations with high-risk drugs can be fatal. This study aimed to identify the factors influencing the accuracy of high-risk injectable drug concentrations in appliances used for intensive care unit preparation practices. Norepinephrine (NE) was chosen as an example of a high-risk medication drug. The concentration (0.2 and 0.5 mg/mL), the diluent (sodium chloride 0.9% and 5% dextrose), and the container type (prefilled- and empty-infusion bag and syringe) were tested as potential variability factors. An ultraviolet spectrophotometric method was used for NE dosage. 108 NE solutions were prepared by five individuals (pharmacists or laboratory technicians) with clinical experience as well as experience in the aseptic preparation of solutions. The container type was found to be the only factor influencing the accuracy of NE concentration. NE solutions in syringes proved to be the most accurate while preparations in prefilled bags tended to underdose NE.

Critical Care Pharmacists: A Focus on Horizons

Critical care pharmacy has evolved rapidly over the last 50 years to keep pace with the rapid technological and knowledge advances that have characterized critical care medicine. The modern-day critical care pharmacist is a highly trained individual well suited for the interprofessional team-based care that critical illness necessitates. Critical care pharmacists improve patient-centered outcomes and reduce health care costs through three domains: direct patient care, indirect patient care, and professional service. Optimizing workload of critical care pharmacists, similar to the professions of medicine and nursing, is a key next step for using evidence-based medicine to improve patient-centered outcomes.

Investigation of Mental and Physical Health of Nurses Associated with Errors in Clinical Practice

Background: Errors are common among all healthcare settings. The safety of patients is linked directly with nursing errors because nurses stand by them more often than any other healthcare professional. The role of mental and physical health of nurses is of great interest for a good and efficient job performance, but also for maintaining good patient care delivery. This study aimed to investigate the association between nurses’ general health and making errors during clinical practice. Methods: A total of 364 nurses completed a specially designed questionnaire anonymously and voluntarily. The sample consisted of nurses with all educational degrees. The questionnaire included demographic data and questions about general health issues, resilience status and nurses’ possible experience with errors within a hospital. Results: 65,8% of the participants stated that at least one error had happened at their workplace, and 49,4% of them reported that the error was caused by them. Somatic symptoms were found to have a positive correlation with making errors (p < 0.001). However, the other aspects of general health, which were anxiety/insomnia, social dysfunction and severe depression, had no statistical significance with adverse events. The most common type of error reported (65,5%) was a medication adverse event. Resilience level was found to be statistically significant (p < 0.001) when correlated with all aspects of general health (anxiety/insomnia, severe depression, somatic symptoms), but not with social dysfunction. Conclusion: Nurses are affected by their somatic symptoms in their daily clinical practice, making them vulnerable to making errors that compromise patient safety. A high resilience level could help them cope with unfavorable situations and prevent them from doing harm to a patient or themselves.

Medication Prescription Errors in Intensive Care Unit: An Avoidable Menace

How to cite this article: Juneja D, Mishra A. Medication Prescription Errors in Intensive Care Unit: An Avoidable Menace. Indian J Crit Care Med 2022;26(5):541-542.

Medication Errors at a Tertiary Hospital Intensive Care Unit

Background

The intensive care unit (ICU) generates more medication prescriptions per patient day than any other unit in the hospital. The dynamics of the ICU environment, coupled with the complexity of patient pathology, increases the risk of medication errors. This study aimed to evaluate the incidence and spectrum of medication errors in an adult general ICU in Johannesburg, South Africa.

Methods

A retrospective chart review was conducted at a 19-bed ICU in a tertiary-level hospital in Johannesburg. Data were independently collected by two of the study investigators. The doctors’ prescription and the nurses’ administration section of patient bedside charts were scrutinized for drug prescription and administration errors.

Results

Of the 656 patient days studied, 3237 drugs (5.6 drugs per patient day) were prescribed. There were a total of 359 medication errors, comprising 237 (66.0%) prescription and 122 (34.0%) administration errors. The total error rate per 1000 patient days was 621.1, while the total error rate per 1000 drug prescriptions was 110.9. The most common errors were incorrect dose prescribed (n=69, 19.2%), incorrect dosing interval prescribed (n=48, 13.4%), incorrect dose administered (n=42, 11.7%) and failure to administer the prescribed drug (n=38, 10.6%).

Conclusion

The overall occurrence of medication errors is high but is in keeping with general international trends. Targeted interventions should be implemented to minimize the frequency of medication errors in the ICU and consequent risk to patients.

Effect and associated factors of a clinical pharmacy model in the incidence of medication errors in the hospital Pablo Tobón Uribe eacpharmodel study: stepped wedge randomized controlled Trial (NCT03338725)

Background The World Health Organization considers medication errors to be an issue that requires attention at all levels of care, to reduce the severe and preventable harm related to drug therapy. Different standards for clinical pharmaceutical practices have been proposed by various organizations across the world, where the pharmacist, as part of the multidisciplinary health team, can help improve patient safety. Objective To assess the impact of the introduction of a clinical pharmacy practice model on medication error in patients of a university hospital. Setting The study was conducted in a tertiary care hospital, Medellín, Colombia. Methods A randomized, controlled cluster-wedge staggered trial with a duration of 14 months was conducted to compare the clinical pharmacy practice model with the usual care process in the hospital. Five hospital health care units were included, which were initially assigned to the control group, and after an observation period of 2 months, they were randomly assigned to the intervention group. The trial protocol was registered in ClinicalTrials.gov (identifier NCT03338725). Main outcome measure The incidence of medication errors in hospitalized patients was the main outcome measure. Results The incidence of medication error was 13.3% and 22.8% for the intervention group and control group, respectively. The probability of presenting a medication error was 48% lower when the patient was in the intervention group (RR 0.52; 95% CI: 0.34-0.79). The probability of presenting a medication error over time was 44% lower in the intervention group (p = 0.0005); meanwhile, the resolution of a medication error over time was 70% higher in the intervention group (p = 0. 0029). Conclusion The clinical pharmacy practice model, made up of strategies focused on reducing medication errors, significantly reduces medication errors in patients during hospitalization compared with usual practice. This work assessed the effect of a clinical pharmacy model on the incidence of medication errors and demonstrated its effectiveness in reducing these errors in hospitalized patients. Trial registration ClinicalTrials.gov, NCT03338725. Registered on 9 November 2017. First patient randomized on February 2, 2018.

A clinical pharmacist-led integrated approach for evaluation of medication errors among medical intensive care unit patients

AIM

Medication errors jeopardize the safety of critically ill patients. Using only one method for the detection of medication errors may not reflect an existing picture of patient safety accurately. Therefore, we designed a clinical pharmacist-led integrated approach to evaluate incidence rate, type, and severity of medication errors and preventable adverse drug events (ADEs) and to assess the impact of the implementation of interventions recommended by the clinical pharmacist.

METHODS

A prospective study was conducted from November 2017 to January 2019 in the medical ICU. The clinical pharmacist performed a combination of medication error detection methods, which included medication chart review, patient monitoring until discharge/death, and attending medical rounds. Detected medication errors were intervened with prescribers. Based on the prescribers' decision on delivered interventions, patients were divided into two groups: A (clinical pharmacist's interventions were implemented), and B (clinical pharmacist's interventions were not implemented). We compared patients' outcomes obtained from study groups to evaluate the impact of the implementation of interventions performed by the clinical pharmacist.

RESULTS

A total of 271 medication errors (122.62 per 1000 patient hospital-days) were detected among the study patients (n = 228). Drug-drug interactions (70, 25.8%), guideline nonconformity (51, 18.8%), and inadequate drug monitoring (29, 11%) were the most common types of detected medication errors. Eighty-six percentage of the clinical pharmacist's interventions were implemented by prescribers. Approximately half of medication errors were intercepted before reaching to patients who received the clinical pharmacist's interventions (group A). Overall, medication errors induced 33 preventable ADEs (14.93 per 1000 patient hospital-days), of which the number of preventable ADEs was significantly greater in group B (P < 0.0001). Significantly in group B, detected medication errors initiated chains of consecutive errors when the clinical pharmacist's interventions were not accepted. Also, this group had significantly increased length of stay (P < 0.0001), number of deaths (P = 0.0312), and more than a three-fold greater number of patients intratransferring to higher levels of care (P = 0.0235; odds ratio, 3.41; 95% confidence interval, 1.08-10.8).

CONCLUSION

The clinical pharmacist-led integrated approach revealed that medication errors commonly occurred among critically ill patients, and the clinical pharmacist's interventions intercepted the majority of these medication errors. The number of preventable ADEs was significantly fewer in a group of patients who received these interventions. However, medication errors formed chains of errors that adversely affected patients' investigated outcomes in the study group with no implementation of the clinical pharmacist interventions.

The effect of different intensivist staffing patterns on the rate of potential drug-drug interactions in adult trauma intensive care units

BACKGROUND

Drug-drug interactions (DDIs) have created alarming challenges for public health, especially in those admitted to intensive care units (ICUs). Many studies have shown that involvement of intensivists in the ICUs improves the outcome and decreases the treatment costs. The effect of academic versus non-academic (therapeutic) intensivist as well as hours of coverage and attendance of intensivist on potential DDIs (pDDIs) was evaluated in six adult trauma ICUs of a level one trauma center.

METHODS

In this 6-month cross-sectional study, 200 patients were included. The DDIs were classified into five groups, including type A, B, C, D, and X. pDDIs were defined as interactions belonged to C, D and X categories. Patients in six adult ICUs with three different patterns of intensivist staffing models including type A (once-daily therapeutic intensivist visit followed by 24 h on-call), B (twice-daily academic intensivist visit, 8 h of attendance in ICU and 16 h on-call) and C (all criteria just like ICU type B, except for the presence of therapeutic instead of academic intensivist) were screened for pDDIs.

RESULTS

In total, 3735 drug orders and 3869 drugs (193 different types) were screened and 1826 pDDIs were identified. Type C, D and X interactions accounted for 60.6%, 35.5%, and 3.9% of all pDDIs, respectively. The mean of pDDI per patient was significantly higher (p-value < 0.001) in the ICU type A than ICU types C and B. The frequency of pDDIs was the highest in the type A ICUs. A statistically significant relationship was observed between the number of prescribed drugs and ICU length of stay (p-value < 0.001 and p = 0.009, respectively).

CONCLUSION

Different patterns of intensivist staffing affect pDDIs to varying degrees. In the studied ICUs academic versus therapeutic intensivist, twice versus once-daily visit, and 8 h attendance with16 h on-call versus 24 h on-call were associated with more reductions in pDDIs.

PLAIN LANGUAGE SUMMARY

The impact of different intensivist staffing patterns in ICUs on the rate of potential drug-drug interactionsDrug-drug interactions (DDIs) have created alarming challenges for public health, especially in patients admitted to intensive care units (ICUs). Many studies have shown that involvement of intensivists in the ICUs improves the outcome and limits the costs. Considering the high incidence of potential DDIs (pDDIs) occurring for critically ill patients and the importance of ADRs caused by pDDIs in ICUs, the effect of the presence of an academic versus therapeutic intensivist, as well as the hour of coverage of intensivist on prevalence of pDDIs was evaluated in six adult trauma ICUs of a level one trauma center in Shiraz, Iran. We also determined the prevalence of pDDIs and their associated risk factors. To the best of our knowledge, this is the first study that has assessed the effect of various ICU physician staffing models on the incidence and pattern of pDDIs.

Pharmacy Personnel's Involvement in Transitions of Care of Intensive Care Unit Patients: A Systematic Review

OBJECTIVE

Do pharmacy personnel- (ie, pharmacist or pharmacy technician) driven interventions at transitions of care into or out of the intensive care unit (ICU) improve medication safety measures compared to interventions made by other health-care team members or no intervention?

DATA SOURCES

A literature search of MEDLINE and Embase limited to English language and humans was performed (from 1969 until January 2019). Bibliographies of included investigations were reviewed for additional citations.

METHODS

Investigations were selected if they described a pharmacy-driven intervention at any point of transfer into or out of an ICU setting. Ten investigations were included. Five described interventions relevant to the entire ICU population, and 5 described interventions targeted to specific medications or disease.

RESULTS

A variety of interventions were utilized in the 10 included investigations. A significant improvement was demonstrated with pharmacy-driven intervention in all 4 studies that evaluated the entire ICU patient population. Interventions specific to certain medication and disease improved medication safety measures but were not always statistically significant. Medication error rates are high in patients transferred into and out of the ICU, and limited data exist to address this concern. This review compares and evaluates the current literature to guide future interventions and research in this area.

CONCLUSIONS

Although pharmacy-driven interventions demonstrated some benefit in various medication safety measures in the majority of studies, additional randomized and prospective trials with patient-centered outcomes that assess morbidity and mortality are needed.

Clinical Practice Guideline: Safe Medication Use in the ICU

OBJECTIVE

To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill.

DATA SOURCES

PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015.

STUDY SELECTION

Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed.

DATA EXTRACTION

Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation.

DATA SYNTHESIS

The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations.

CONCLUSIONS

This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

Potential Drug-Drug Interactions Among Critically Ill Pediatric Patients in a Tertiary Pulmonary Center

Patients in the pediatric intensive care unit (PICU) are at increased risk of potential drug-drug interactions (pDDIs) because of the complexity of pharmacotherapy. The current study aimed to assess the rate, pattern, risk factors, and management of pDDIs in the PICU of an academic pulmonary hospital. A prospective observational study was conducted for 6 months. Pharmacotherapy data of PICU-admitted patients were evaluated by a clinical pharmacologist. Interacting drugs, reliability, mechanism, potential outcome, and clinical management of pDDIs were identified using the Lexi-Interact database. Logistic regression was applied to analyze the risk factors that could be associated with the interactions. One hundred and twenty-three medication profiles were evaluated during the study period. Diseases of the respiratory system were the main diagnoses among intensive care unit (ICU)-admitted patients (56.1%). A total of 38.6% of the patients exposed to at least 1 major and/or contraindicated interaction during ICU admission. Most pDDIs occurred through metabolic (35.4%) and additive (34.8%) mechanisms. The existence of pDDIs was significantly associated with the number of prescribed medications. Exposure to pDDIs is frequent in critically ill pediatric patients and related to the number of medications. Daily and close cooperation between clinicians and clinical pharmacologists is recommended to prevent harmful outcomes of DDIs.

A Prospective Analysis of Drug Interactions in Patients of Intensive Cardiac Care Unit

INTRODUCTION

Drug-Drug Interaction (DDI) is a serious concern in cardiac patients due to polypharmacy.

AIM

The present study was aimed to identify the potential DDI among hospitalized cardiac patients and evaluate the mechanism and severity of such interactions.

MATERIALS AND METHODS

A prospective observational study was conducted in intensive cardiac care unit of a tertiary care hospital for six months. Patients aged 18 years and above and taking two or more drugs were included in the study. Medscape drug interaction checker was used to identify and analyze the pattern of potential DDI.

RESULTS

Out of 500 patients, most of the patients were male (78.4%) in the age group of 50-60 years (31%). The most common diagnosis was acute coronary syndrome (57.2%). Out of total 2849 DDI, 2194 (77.01%) were pharmacodynamic, 586 (20.57%) were pharmacokinetic in nature while 69 (2.42%) drug pairs interacted by unknown mechanism. Majority of drug interactions were significant {2031 (71.29%)} in nature followed by minor {725(25.45%)} while serious drug interactions were observed in only 93 (3.26%) drug pairs. A positive correlation was observed between patient's age and number of drugs prescribed (r=0.178, p<0.001), number of drugs prescribed and potential Drug-Drug Interaction (pDDI) (r= 0.788, p<0.001) and between patient's age and pDDI (r=0.338, p<0.001).

CONCLUSION

The risk of pDDI was more commonly observed in elderly male patients particularly with antiplatelet drugs like low dose aspirin and clopidogrel.

Pharmacist recommendations in an intensive care unit: three-year clinical activities

Objective

To analyze the clinical activities performed and the accepted pharmacist recommendations made by a pharmacist as a part of his/her daily routine in an adult clinical intensive care unit over a period of three years.

Methods

A cross-sectional, descriptive, and exploratory study was conducted at a tertiary university hospital from June 2010 to May 2013, in which pharmacist recommendations were categorized and analyzed.

Results

A total of 834 pharmacist recommendations (278 per year, on average) were analyzed and distributed across 21 categories. The recommendations were mainly made to physicians (n = 699; 83.8%) and concerned management of dilutions (n = 120; 14.4%), dose adjustment (n = 100; 12.0%), and adverse drug reactions (n = 91; 10.9%). A comparison per period demonstrated an increase in pharmacist recommendations with larger clinical content and a reduction of recommendations related to logistic aspects, such as drug supply, over time. The recommendations concerned 948 medications, particularly including systemic anti-infectious agents.

Conclusion

The role that the pharmacist played in the intensive care unit of the institution where the study was performed evolved, shifting from reactive actions related to logistic aspects to effective clinical participation with the multi-professional staff (proactive actions).

Clinical decision support for drug related events: Moving towards better prevention

Clinical decision support (CDS) systems with automated alerts integrated into electronic medical records demonstrate efficacy for detecting medication errors (ME) and adverse drug events (ADEs). Critically ill patients are at increased risk for ME, ADEs and serious negative outcomes related to these events. Capitalizing on CDS to detect ME and prevent adverse drug related events has the potential to improve patient outcomes. The key to an effective medication safety surveillance system incorporating CDS is advancing the signals for alerts by using trajectory analyses to predict clinical events, instead of waiting for these events to occur. Additionally, incorporating cutting-edge biomarkers into alert knowledge in an effort to identify the need to adjust medication therapy portending harm will advance the current state of CDS. CDS can be taken a step further to identify drug related physiological events, which are less commonly included in surveillance systems. Predictive models for adverse events that combine patient factors with laboratory values and biomarkers are being established and these models can be the foundation for individualized CDS alerts to prevent impending ADEs.

Impact of the implementation of vasoactive drug protocols on safety and efficacy in the treatment of critically ill patients

WHAT IS KNOWN AND OBJECTIVE

The correct management of high-alert medications is a priority issue in expert recommendations for improving the clinical safety of patients. Objectives were to assess the impact of the implementation of vasoactive drug (VAD) protocols on safety and efficacy in the treatment of critically ill patients.

METHODS

A prospective before-and-after study on the implementation of different VAD protocols, comparing medication errors (MEs) rates, mean intensive care unit (ICU) stay, mean blood pressure (MAP), heart rate (HR) and oxygen saturation.

RESULTS AND DISCUSSION

The study included 432 patients. There was a statistically significant decrease in prescribing errors (55·9%), validation errors (68·1%) and medication administration records (MAR) errors (78·8%). No differences were found between the two phases in ICU stay, MAP, HR and oxygen saturation.

WHAT IS NEW AND CONCLUSION

Implementation of protocols decreases variability in clinical practice, reduces the incidence of MEs and maintains the effectiveness of VAD therapy in critically ill patients.

Important drug classes associated with potential drug-drug interactions in critically ill patients: highlights for cardiothoracic intensivists

BACKGROUND

Patients in the intensive care unit (ICU) are more prone to drug-drug interactions (DDIs). The software and charts that indicate all interactions may not be proper for clinical usage. This study aimed to identify the main drug classes associated with clinically significant DDIs in cardiothoracic ICU and categorize DDIs to make cardiothoracic intensivists aware of safe medication usage.

METHODS

This prospective study was conducted over 6 months in a cardiothoracic ICU of a university-affiliated teaching hospital. The presence of potential drug-drug interactions (pDDIs) was assessed by a clinical pharmacologist using Lexi-Interact database. Clinically significant pDDIs were defined according to severity and reliability rating. Interacting drug classes, mechanisms, and recommendations were identified for each interaction.

RESULTS

From 1780 administered drugs, 496 lead to major (D) and contraindicated (X) interactions. Nine drug classes were responsible for D and/or X interactions with excellent (E) and/or good (G) reliability. Anti-infective agents (45.87 %) were the main drug classes that caused clinically significant pDDIs followed by central nervous system drugs (14.67 %). Azole antifungals as the most interacting antimicrobial agents precipitated metabolism inhibition of CYP3A substrates.

CONCLUSIONS

Clinically significant pDDIs as potential patient safety risks were prevalent in critically ill patients. The findings from current study help to improve knowledge and awareness of clinicians in this area and minimize adverse events due to pDDIs.

Prevalência de incidentes relacionados à medicação em unidade de terapia intensiva

Objetivo Estimar a prevalência de incidentes relacionados à medicação em uma Unidade de Terapia Intensiva. Métodos Estudo transversal que incluiu 116 registros de internações hospitalares no período de 12 meses. O instrumento de pesquisa foi elaborado com base nas variáveis de estudo e validado por dois experts. A prevalência foi calculada considerando o número de internações expostas como numerador e o total de internações investigadas como denominador, calculando intervalo de confiança de 95%. Para a verificação de associação significativa entre as variáveis, utilizou-se o Teste Exato de Fisher, assumindo nível de significância máximo de 5% (p<0,05). Resultados Verificou-se que 113 internações foram expostas a pelo menos um tipo de incidente, totalizando 2.869 ocorrências, sendo 1.437 circunstâncias notificáveis, 1.418 incidentes sem dano, nove potenciais eventos adversos e cinco eventos adversos. Os incidentes aconteceram durante a fase da prescrição (45,4%) e a ausência de conduta dos profissionais de saúde frente aos incidentes foi identificada em 99% dos registros. Conclusão Estimou-se prevalência de 97,4% incidentes relacionados à medicação.

The prevalence of long QT interval in post-operative intensive care unit patients

The severity of patient illnesses and medication complexity in post-operative critically ill patients increase the risk for a prolonged QT interval. We determined the prevalence of prolonged QTc in surgical intensive care unit (SICU) patients. We performed a prospective cross-sectional study over a 15-month period at a major academic center. SICU pre-admission and admission EKGs, patient demographics, and laboratory values were analyzed. QTc was evaluated as both a continuous and dichotomous outcome (prolonged QTc > 440 ms). 281 patients were included in the study: 92 % (n = 257) post-operative and 8 % (n = 24) non-operative. On pre-admission EKGs, 32 % of the post-operative group and 42 % of the non-operative group had prolonged QTc (p = 0.25); on post-admission EKGs, 67 % of the post-operative group but only 33 % of the non-operative group had prolonged QTc (p < 0.01). The average change in QTc in the post-operative group was +30.7 ms, as compared to +2 ms in the non-operative group (p < 0.01). On multivariable adjustment for long QTc as a dichotomous outcome, pre-admission prolonged QTc (OR 3.93, CI 1.93-8.00) and having had an operative procedure (OR 4.04, CI 1.67-9.83) were associated with developing prolonged QTc. For QTc as a continuous outcome, intra-operative beta-blocker use was associated with a statistically-significant decrease in QTc duration. None of the patients developed a lethal arrhythmia in the ICU. Prolonged QTc is common among post-operative SICU patients (67 %), however lethal arrhythmias are uncommon. The operative experience increases the risk for long QTc.

Mannitol dosing error during interfacility transfer for intracranial emergencies

OBJECT

Mannitol is commonly used to treat elevated intracranial pressure (ICP). The authors analyzed mannitol dosing errors at peripheral hospitals prior to or during transport to tertiary care facilities for intracranial emergencies. They also investigated the appropriateness of mannitol use based on the 2007 Brain Trauma Foundation guidelines for severe traumatic brain injury.

METHODS

The authors conducted a retrospective review of the Shock Trauma Air Rescue Society (STARS) electronic patient database of helicopter medical evacuations in Alberta, Canada, between 2004 and 2012, limited to patients receiving mannitol before transfer. They extracted data on mannitol administration and patient characteristics, including diagnosis, mechanism, Glasgow Coma Scale score, weight, age, and pupil status.

RESULTS

A total of 120 patients with an intracranial emergency received a mannitol infusion initiated at a peripheral hospital (median Glasgow Coma Scale score 6; range 3-13). Overall, there was a 22% dosing error rate, which comprised an underdosing rate (<0.25 g/kg) of 8.3% (10 of 120 patients), an overdosing rate (>1.5 g/kg) of 7.5% (9 of 120), and a nonbolus administration rate (>1 hour) of 6.7% (8 of 120). Overall, 72% of patients had a clear indication to receive mannitol as defined by meeting at least one of the following criteria based on Brain Trauma Foundation guidelines: neurological deterioration (11%), severe traumatic brain injury (69%), or pupillary abnormality (25%).

CONCLUSIONS

Mannitol administration at peripheral hospitals is prone to dosing error. Strategies such as a pretransport checklist may mitigate this risk.

Reducing medication errors in critical care: a multimodal approach

The Institute of Medicine has reported that medication errors are the single most common type of error in health care, representing 19% of all adverse events, while accounting for over 7,000 deaths annually. The frequency of medication errors in adult intensive care units can be as high as 947 per 1,000 patient-days, with a median of 105.9 per 1,000 patient-days. The formulation of drugs is a potential contributor to medication errors. Challenges related to drug formulation are specific to the various routes of medication administration, though errors associated with medication appearance and labeling occur among all drug formulations and routes of administration. Addressing these multifaceted challenges requires a multimodal approach. Changes in technology, training, systems, and safety culture are all strategies to potentially reduce medication errors related to drug formulation in the intensive care unit.

Medication error reporting in a university teaching hospital in Saudi Arabia

OBJECTIVES

Medication errors are common in the hospital setting. Little is known about these errors in Saudi Arabia. The objective of the current study was to explore the rate of reporting medication errors and factors associated with the root causes of these errors in a large tertiary teaching hospital in Saudi Arabia.

METHODS

This study was conducted at the university teaching hospital in Riyadh, Saudi Arabia. All occurrence/variant reports related to medication errors were documented on a hospital Web-based medication error form that was designed to capture information on all aspects. Medication error reports were reviewed and reported at quarterly intervals over a 1-year period (November 2009 to October 2010).

RESULTS

The medication error rate over the 1-year study period was 0.4% (949 medication errors for 240,000 prescriptions). During this period, 14 (1.5%) errors were categorized as resulting in any harm to the patient (all category E). Medication errors were reported predominantly at the prescribing stage of the medication process (89%). The most common types of errors were prescribing (44%) and improper dose/quantity (31%). Antibiotics (12%), antihypertensive agents (10%), and oral hypoglycemic agents (8%) were the pharmacological classes of medication most commonly involved with errors. Nonspecific performance deficit (43%), knowledge deficit (28%), and illegible or unclear handwriting (17%) were the main reported causes of error.

CONCLUSIONS

Medication errors are underreported in a tertiary teaching hospital in Riyadh, Saudi Arabia. Future studies should evaluate the effectiveness of interventions to stimulate medication errors reporting by health-care providers.

A survey of medication error prevalence in a Brazilian health center

Medication error is a frequent adverse event in health care. In this study, we checked each medication dose in 744 medical orders and identified a prevalence rate of 0.53 medication errors per medical order. The highest prevalence was in the critical care unit (0.98), and the most frequent type was dose omission (53%). The results were published bimonthly for health care professionals, with an improvement recommendation list to minimize medication errors and increase patient safety.

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units

OBJECTIVE

To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process.

METHODS

Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process.

RESULTS

An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16-24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process.

CONCLUSIONS

Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.

Effects of the implementation of a preventive interventions program on the reduction of medication errors in critically ill adult patients

PURPOSE

Medication errors (MEs) are a major factor limiting the effectiveness and safety of pharmacological therapies in critically ill patients. The purpose was to determine if a preventive interventions program (PIP) is associated with a significant reduction on prevalence of patients with MEs in intensive care unit (ICU).

METHODS

A prospective before-after study was conducted in a random sample of adult patients in a medical-surgical ICU. Between 2 observational phases, a PIP (bundle of interventions to reduce MEs) was implemented by a multidisciplinary team. Direct observation was used to detect MEs at baseline and postintervention. Each medication process, that is, prescription, transcription, dispensing, preparation, and administration, was compared with what the prescriber ordered; if there was a difference, the error was described and categorized. Medication errors were defined according to the National Coordinating Council for Medication Error Reporting and Prevention.

RESULTS

A total of 410 medications for 278 patients were evaluated. A 31.7% decrease on the prevalence of patients with MEs (41.9%-28.6%; P < .05) was seen. Main variations occurred in anti-infectives for systemic use and prescription and administration stage.

CONCLUSIONS

The implementation of PIP by a multidisciplinary team resulted in a significant reduction on the prevalence of patients with ME at an adult ICU.

[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.

Streamlining the medication process improves safety in the intensive care unit

BACKGROUND

Multiple interventions were made to optimize the medication process in our intensive care unit (ICU). 1 Transcriptions from the medical order form to the administration plan were eliminated by merging both into a single document; 2 the new form was built in a logical sequence and was highly structured to promote completeness and standardization of information; 3 frequently used drug names, approved units, and fixed routes were pre-printed; 4 physicians and nurses were trained with regard to the correct use of the new form. This study was aimed at evaluating the impact of these interventions on clinically significant types of medication errors.

METHODS

Eight types of medication errors were measured by a prospective chart review before and after the interventions in the ICU of a public tertiary care hospital. We used an interrupted time-series design to control the secular trends.

RESULTS

Over 85 days, 9298 lines of drug prescription and/or administration to 294 patients, corresponding to 754 patient-days were collected and analysed for the three series before and three series following the intervention. Global error rate decreased from 4.95 to 2.14% (-56.8%, P < 0.001).

CONCLUSIONS

The safety of the medication process in our ICU was improved by simple and inexpensive interventions. In addition to the optimization of the prescription writing process, the documentation of intravenous preparation, and the scheduling of administration, the elimination of the transcription in combination with the training of users contributed to reducing errors and carried an interesting potential to increase safety.

Medication Error Minimization Scheme (MEMS) in an adult tertiary intensive care unit (ICU) 2009-2011

INTRODUCTION

The Medication Error Minimisation Scheme (MEMS) is a locally based ongoing multidisciplinary, multifaceted quality improvement (QI) project within an Australian adult tertiary level Intensive Care Unit (ICU). The project commenced in 2009. Its primary aim is to enhance medication safety within this ICU by utilising existing resources. The aim of this paper is to provide a descriptive account of the various activities, interventions and results of this project within the first three years.

METHODS

The research design for this project was based upon Plan-Do-Study-Act (PDSA) cycles associated with QI projects. Medication error rates and audits of: intravenous infusions, incompatible intravenous medications and incorrect documentation of withheld medications were analyzed according to simple statistical techniques. Initial and follow up medication safety surveys were compared using basic statistical analysis. Focus groups exploring barriers and enablers of medication incident reporting were analyzed according to qualitative techniques associated with focus group discussions. Other interventions included: regular education sessions; discussions within other departmental meetings such as nursing staff meetings and Morbidity and Mortality meetings; and bedside discussions and demonstrations. Promotion of medication safety occurred within a number of forums; activities and findings were advertised and displayed; a recognizable Logo for MEMS was employed; and incentives were provided for staff.

RESULTS

Reported Medication Incidents (MIs) increased from 6.2 to 14.9 MIs per 1000 patient days. Audits and chart reviews confirmed that more MIs are uncovered by employing a variety of techniques in addition to incident reporting. Staff surveys provided a rich source of information regarding medication safety. Audits of intravenous infusions revealed a reduced error rate from 38/331 (11.5%) to 15/468 (3.2%). Chart review of incorrect documentation of omitted medications decreased from 105/347 (30.3%) to 104/486 (21.4%). Focus groups provided information that was able to be used in a number of hospital forums in order to explain the impact of existing systems upon ICU staff.

CONCLUSION

This ongoing QI project was able to achieve its targeted goals. The MI reporting rate was increased. This project demonstrated that measurable, "non-incident report" errors can be reduced by focusing upon and promoting medication safety in the ICU. These activities demonstrated a workplace that values medication safety, the discovery of shortfalls and the benefits of ongoing improvement.

Terms used in patient safety related to medication: a literature review

PURPOSE

There is a lack of homogeneity in the terminology used in the context of patient safety related to medication. The aim of this review was to identify the terms and definitions used in patient safety related to medication within the scientific literature.

METHODS

Original and review articles that were indexed between 1998 and 2008 in MEDLINE and EMBASE and contained terms used in patient safety related to medication were included. Terms and definitions were extracted and categorised according to whether its definition referred to the process of medication use, or to the clinical outcome of medication use, or both.

RESULTS

Of 2564 articles, 147 were included. Sixty terms used in patient safety related to medication with 189 different definitions were identified. Among terms that referred only to the process of medication use (n = 23), medication error provided the greatest number of definitions (n = 29). Among terms that referred only to the clinical outcome of medication use (n = 31), adverse drug event provided the greatest number of definitions (n = 15). Finally, among terms that referred both to the process of use and to the clinical outcome of medication use (n = 13), drug-related problem provided the greatest number of definitions (n = 7).

CONCLUSIONS

A multitude of terms and definitions are used in patient safety related to medication. This heterogeneity makes it difficult to compare the results among studies and to appreciate the true magnitude of the problem. Classifying and unifying the terminology is necessary to advance in patient safety strategies.

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.

Reducing prescribing errors in the paediatric intensive care unit: an experience from Egypt

AIM

To investigate the impact of different measures, implemented by clinical pharmacists, on prescribing error rates in a paediatric intensive care unit (PICU) in Cairo, Egypt.

METHODS

We performed a pre-post study of prescribing errors in a 12 bed PICU. We utilized a chart review method for the detection of prescribing errors. The rate and potential severity of prescribing errors were determined before and then after the implementation of the medication error reducing measures. These measures included the use of a new structured medication order chart, physician education, provision of dosing assists and physician performance feedback.

RESULTS

We evaluated 1417 medication orders for 139 patients preintervention and 1097 orders for 101 patients postintervention. Of preintervention orders, 1107 (78.1%) had at least one prescribing error. The intervention resulted in significant reduction in prescribing error rate to 35.2% postintervention (p < 0.001). The intervention resulted also in a significant reduction in the rate of potentially severe errors from 29.7% preintervention to 7% postintervention (p < 0.001) and the rate of potentially moderate errors from 39.8% preintervention to 24.2% postintervention (p < 0.001). Besides, rates of all types of prescribing errors were declined to different degrees as a result of the intervention.

CONCLUSION

Clinical pharmacists' activities, focusing on improving physician-nurse communication, physician drug knowledge and awareness of errors, were shown effective in reducing the rate of prescribing errors and their potential severity in a PICU.

Major sources of critical incidents in intensive care

Introduction

In recent years, critical incident (CI) reporting has increasingly been regarded as part of ongoing quality management. CI databanks also aim to improve health and safety issues for patients as well as staff. The aim of this study was to identify frequent causes of adverse events in critical care with the potential to harm patients, staff or visitors by analysing data from a voluntary and optionally anonymous critical incident reporting system.

Methods

The study includes all critical incidents reported during a 90-month period in a 13-bed adult general intensive care unit (ICU). Reporting of incidents was performed via an electronic reporting system or by a manual critical incident report. All CIs were classified in the following main categories: equipment, administration, pharmaceuticals, clinical practice, and health & safety hazards. The overall distribution of incidents within the different categories was compared with the regional database of ICUs in the Cheshire and Mersey region of northwest England for 2008.

Results

A total of 1127 CIs were reported during the study period. The frequencies within the main categories were: equipment 338 (30%), clinical practice 257 (22.8%), pharmaceuticals 238 (21.1%), administration 213 (18.9%), health and safety hazards 81 (7.2%). The regional database had a similar frequency of critical incidents within the different categories, suggesting that our results may reflect a general distribution pattern of CIs in intensive care.

Conclusions

Critical incident reporting helps to identify frequent causes of adverse events in critical care. Improvements in quality of care following implementation of preventative strategies such as introduction of regular equipment training sessions will have to be assessed further in future studies.

Erros de medicação em pediatria

A segurança do paciente constitui problema de saúde pública, e erros com medicamentos são os mais freqüentes e graves. O artigo apresenta características epidemiológicas dos erros de medicação em diferentes áreas de atendimento pediátrico, e aponta estratégias de prevenção. Aproximadamente 8% das pesquisas sobre erros de medicação identificadas em bases de dados nacionais e internacionais referem-se à população pediátrica. Crianças apresentam maior vulnerabilidade à ocorrência de erros devido a fatores intrínsecos, destacando-se características anatômicas e fisiológicas; e extrínsecos, relativos à falta de políticas de saúde e da indústria farmacêutica voltadas ao atendimento de tais especificidades. As evidências apontam para a necessidade de implementação de estratégias de prevenção de erros de medicação, contribuindo para promover a segurança do paciente.

Computerized detection of adverse drug reactions in the medical intensive care unit

OBJECTIVE

Clinical event monitors are a type of active medication monitoring system that can use signals to alert clinicians to possible adverse drug reactions. The primary goal was to evaluate the positive predictive values of select signals used to automate the detection of ADRs in the medical intensive care unit.

METHOD

This is a prospective, case series of adult patients in the medical intensive care unit during a six-week period who had one of five signals presents: an elevated blood urea nitrogen, vancomycin, or quinidine concentration, or a low sodium or glucose concentration. Alerts were assessed using 3 objective published adverse drug reaction determination instruments. An event was considered an adverse drug reaction when 2 out of 3 instruments had agreement of possible, probable or definite. Positive predictive values were calculated as the proportion of alerts that occurred, divided by the number of times that alerts occurred and adverse drug reactions were confirmed.

RESULTS

145 patients were eligible for evaluation. For the 48 patients (50% male) having an alert, the mean±SD age was 62±19 years. A total of 253 alerts were generated. Positive predictive values were 1.0, 0.55, 0.38 and 0.33 for vancomycin, glucose, sodium, and blood urea nitrogen, respectively. A quinidine alert was not generated during the evaluation.

CONCLUSIONS

Computerized clinical event monitoring systems should be considered when developing methods to detect adverse drug reactions as part of intensive care unit patient safety surveillance systems, since they can automate the detection of these events using signals that have good performance characteristics by processing commonly available laboratory and medication information.

On the integration and standardization of medication error data: taxonomies, terminologies, causes and contributing factors

OBJECTIVE

A reliable database on the causes and contributing factors of medication errors can inform strategies for their prevention. To form a single database from multiple databases requires a process of integration that both maximizes the utility of the new data and minimizes the loss of information. Unfortunately, the terminologies used by different studies and databases may limit integration; therefore, terminologies must be standardized prior to integration.

METHODS

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Taxonomy of Medication Errors was applied to standardize the different terminologies in 11 studies that reported the causes or contributing factors of medication errors.

RESULTS

After standardization, 57% of the reported causes and contributing factors were integrated to form a database while 43% were not integrated because the terminologies could not be standardized or were not similar to the taxonomy.

CONCLUSIONS

This study highlights the challenges to standardizing and integrating databases and the importance of adopting and applying a standardized terminology to record medical errors.

Grading the severity of drug-drug interactions in the intensive care unit: a comparison between clinician assessment and proprietary database severity rankings

BACKGROUND

Computerized provider order entry with decision support software offers an opportunity to identify and prevent medication-related errors, including drug-drug interactions (DDIs), through alerting mechanisms. However, the number of alerts generated can overwhelm and lead to "alert fatigue." A DDI alert system based on severity rankings has been shown to reduce alert fatigue; however, the best method to populate this type of database is unclear.

OBJECTIVE

To compare the severity ranking of proprietary databases to clinician assessment for DDIs occurring in critically ill patients.

METHODS

This observational, prospective study was conducted over 8 weeks in the cardiac and cardiothoracic intensive care unit. Medication profiles of patients were screened for the presence of DDIs and a severity evaluation was conducted using rankings of proprietary databases and clinician opinion using a DDI severity assessment tool. The primary outcome measure was the number of DDIs considered severe by both evaluation methods.

RESULTS

A total of 1150 DDIs were identified after 400 patient medication profiles were evaluated. Of these, 458 were unique drug pairs. Overall, 7.4% (34/458) were considered a severe interaction based upon proprietary database ratings. The assessment by clinicians ranked 6.6% (30/458) of the unique DDIs as severe. Only 3 interactions, atazanavir-simvastatin, atazanavir-tenofovir, and aspirin-warfarin, were considered severe by both evaluation methods.

CONCLUSIONS

Since proprietary databases and clinician assessment of severe DDIs do not agree, developing a knowledge base for a DDI alert system likely requires proprietary database information in conjunction with clinical opinion.

Adverse drug events in intensive care units: risk factors, impact, and the role of team care

Advances in diagnostic tests, technological interventions, and pharmacotherapy have resulted in spectacular results for many intensive care unit (ICU) patients who, in earlier generations, would have succumbed to their critical illness. At the same time, the complexity and intensity of care required for ICU patients is also associated with greater risks for harm resulting from care. As in other inpatient areas, medications are the most common type of therapy in ICUs and are also associated with the most frequent type of ICU adverse events. Critically ill patients are at high risk for adverse drug events for many reasons, including the complexity of their disease that creates challenges in drug dosing, their vulnerability to rapid changes in pharmacotherapy, the intensive care environment providing ample distractions and opportunity for error, the administration of complex drug regimens, the numerous high-alert medications that they receive, and the mode of drug administration. The clinical outcomes of adverse drug events can result in end-organ damage and even death. The costs of an adverse drug event can be substantial to healthcare systems with an additional $6,000-$9,000 for each event. The multiprofessional patient care team is one approach to promoting patient safety in the ICU.

Medication error in anaesthesia and critical care: A cause for concern

Medication error is a major cause of morbidity and mortality in medical profession, and anaesthesia and critical care are no exception to it. Man, medicine, machine and modus operandi are the main contributory factors to it. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.