[Analysis of an incident notification system and register in a critical care unit]

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.

Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study

BACKGROUND

Medication errors are a serious and complex problem in clinical practice, especially in intensive care units whose patients can suffer potentially very serious consequences because of the critical nature of their diseases and the pharmacotherapy programs implemented in these patients. The origins of these errors discussed in the literature are wide-ranging, although far-reaching variables are of particular special interest to those involved in training nurses. The main objective of this research was to study if the level of knowledge that critical-care nurses have about the use and administration of medications is related to the most common medication errors.

METHODS

This was a mixed (multi-method) study with three phases that combined quantitative and qualitative techniques. In phase 1 patient medical records were reviewed; phase 2 consisted of an interview with a focus group; and an ad hoc questionnaire was carried out in phase 3.

RESULTS

The global medication error index was 1.93%. The main risk areas were errors in the interval of administration of antibiotics (8.15% error rate); high-risk medication dilution, concentration, and infusion-rate errors (2.94% error rate); and errors in the administration of medications via nasogastric tubes (11.16% error rate).

CONCLUSIONS

Nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU.