JAN

ORIGINAL RESEARCH

JOURNAL OF ADVANCED NURSING

Medication errors in an intensive care unit

Elena Bohomol, Lais Helena Ramos & Maria DInnocenzo
Accepted for publication 21 January 2009

Correspondence to E. Bohomol: e-mail: ebohomol@uol.com.br Elena Bohomol MS PhD RN Member of the Nursing and Health Services Evaluation Studies and Research Group Sao Paulo Federal University and Professor of Nursing, Sao Camilo University Center, Sao Paulo, Brazil Lais Helena Ramos PhD RN Professor of Nursing Sao Paulo Federal University and Vice-director of Nursing School, Sao Paulo Federal University, Sao Paulo, Brazil Maria DInnocenzo MS PhD RN Chairwoman Nursing and Health Services Evaluation Studies and Research Group Sao Paulo Federal University and Professor of Nursing, Sao Paulo Federal University, Sao Paulo, Brazil

B O H O M O L E . , R A M O S L . H . & D I N N O C E N Z O M . ( 2 0 0 9 ) Medication errors in an intensive care unit. Journal of Advanced Nursing 65(6), 12591267. doi: 10.1111/j.1365-2648.2009.04979.x

Abstract
Title. Medication errors in an intensive care unit. Aim. This paper is a report of a study to investigating the incidence types and causes of medication errors (MEs) and the consequences for patients. Background. Medication errors are a common problem in hospitals around the world, including those in Brazil. Method. An exploratory, quantitative survey design was used and 44 adult inpatients were studied over a 30-day period in 2006. Three different methods were employed: anonymous self-reports, staff interviews and review of patient prescriptions. Findings. A total of 305 MEs was observed. The mean (SD ) number was 69 (68) per patient. The numbers of MEs per day differed statistically signicantly between the two groups with length of stay in the intensive care unit of <1 week and more than 1 week, respectively, with mean (SD ) of 04 (038) vs. 073 (039) The most frequent types were: omission (711%), wrong time of administration (115%), and prescribing errors (46%). The main causes were: medication not available in the hospital (41%); pharmacy stocking and delivery problems (163%); transcription errors (11%). No death was directly related to any ME. Conclusion. There is a need to develop a culture of safety and quality in patient care. An understanding of the prole of ME types and frequencies in an institution is fundamental to raise awareness and implement measures to avoid them. Structural and procedural changes in hospital organization, with a focus on the efcacy, efciency, and effectiveness of the medication system are needed to reduce MEs. Keywords: adults, anonymous reports, Brazil, healthcare professionals, intensive care, interviews, medication errors, record reviews

Introduction
Research on medication errors (MEs) and the pursuit of safer medication systems began in the 1960s in the United States of America (USA) (Flynn & Barker 1999). In 2000, the book To Err is Human: Building a Safer Health System

was published. This publication is recognized as a landmark because it presented well-conducted studies involving several healthcare institutions concerning MEs and adverse events, and gave birth to profound discussions about (the lack of) safety in healthcare organizations and hospitals (Kohn et al. 2000).
1259

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

E. Bohomol et al.

In Brazil, the rst studies of MEs appeared only in 1990 and were inuenced by quality improvement programmes in healthcare institutions. Unfortunately, quality and safety cultures in patient management are not widely prevalent, as only 2% of the 6594 Brazilian hospitals have adopted methodologies for systematic evaluation of quality established by the two main Brazilian accreditation programmes (CBA 2007, ONA 2008). These numbers are evidence that the Brazilian healthcare system urgently needs to monitor the safety of healthcare delivery and to determine how it can be improved.

Background
Medication errors
Medication errors, dened as any errors in the process of prescribing, dispensing, or administering a drug, whether an adverse consequence occurred or not (Leape et al. 1995), are a common problem in healthcare organizations around the world. Most MEs are preventable; however, when they do occur, besides the great increase in cost, they may also cause serious damage to patients, including death. Although MEs that result in death or serious injury occur infrequently (Kopp et al. 2006), sizable and increasing numbers of people are affected because of the extensive use of drugs in both out-of-hospital and in-hospital settings. An estimated 375 billion drug administrations are done every year to patients in hospitals in the USA. In a review of USA death certicates between 1983 and 1993, it was found that 7391 people died in 1993 from MEs, compared with 2876 people in 1983, representing a 257-fold increase (Kohn et al. 2000). Medication errors occur frequently in hospitals. In a review of 4031 adult admissions to 11 medical and surgical units at two tertiary care hospitals, Bates et al. (1995), identied 247 adverse drug events (ADEs), for an extrapolated event rate of 65 ADEs per 100 non-obstetric admissions, with a mean number of approximately 1900 ADEs per hospital per year. Twenty-eight per cent of these events were judged to be preventable. Another study conducted at two teaching hospitals showed that about two patients out of every 100 admissions experienced a preventable ADE, resulting in average increased hospitals costs of US$ 4700 per admission, or about US$ 28 million annually for a 700-bed teaching hospital (Bates et al. 1997). Several methods of detection of MEs have been described, with different results: anonymous self-report, incident reports, critical incident technique, chart review and direct
1260

observation (Cohen 1999). Chart review could be improved with the trigger tool methodology, which consists of taking a random sample of patient records using triggers (or clues) to identify possible adverse events (Grifn & Resar 2007). One important tool for preventing MEs is learning from past incidents to create awareness of latent conditions leading to errors and to establish an educational strategy (Nichols et al. 2008). This implies using a continuous incident reporting system. The causes of MEs are multifactorial, crossing many lines of responsibility. At the same time, they involve similar circumstances. Leape et al. (1995) dened broad categories in which the underlying problems that result in MEs be found, such as lack of knowledge of the drug, lack of information about the patient, violations of rules, slips and memory lapses, transcription errors, faulty interaction with other services, faulty dose checking, preparation errors and others. Safety systems in healthcare organizations seek to prevent harm to patients, healthcare professionals, contract/agency workers, volunteers and the many other individuals whose activities bring them into a healthcare setting. Safety is one aspect of quality, where quality includes not only avoiding preventable harm, but also making appropriate care available, providing effective services to those who could benet from them, and not delivering ineffective or harmful services (Kohn et al. 2000).

Medication errors in intensive care units

Intensive care units (ICU) are specically prone to having a greater incidence of MEs caused by the treatment of extremely ill patients, with polymedication prescriptions and frequent stressful situations for the staff, commonly occurring in conjunction with work overload in a busy area (Vos et al. 2007). Cullen et al. (1997) studied ve ICUs in two tertiary hospitals in the USA and identied 29 MEs and 77 potential MEs (19 events per 1000 patient-days) in a 6-month period using three techniques of detection: stimulated self-report, review of charts and interviews. Flaatten & Hevroy (1999) found one ME per patient after analysing anonymous reports in an ICU during a 13-month survey, and Calabrese et al. (2001) demonstrated 02 MEs per patient, using the direct observation method. The frequency of MEs reported in the literature varies according to clinical context and staff qualications and also correlates with the methodology of detection used (Schneider & Gift 1998). In spite of being an area of great interest, there are few reports from developing countries such as Brazil on MEs in ICUs.

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Medication errors in an intensive care unit

The study
Aim
The aim of study was to investigate the incidence types and causes of MEs and the consequences for patients.

Design
An exploratory, quantitative survey was conducted.

Classication of consequences of MEs The classication of consequences was based on the Ohio State University Severity Scale (Schneider & Gift 1998). This describes seven levels of severity to the patient: zero, errors intercepted before they reached the patient; one, no change in clinical outcome; two, increased monitoring required; three, additional laboratory tests required, or change in vital signs; four, treatment or procedure required, increased length of stay, or hospital (re)admission; ve, transfer to ICU, invasive procedure, or permanent harmful results and six, contributed to a fatal outcome. Medication system Previously, when aiming to address areas of possible ME occurrences, we found that in the ICU studied there are 40 steps governing drug prescription, transcription, dispensing and administration procedures. The prescribing process is started by a physician, who enters the prescription into a dedicated computer system and prints, revises, and signs it. The nurse plans the medication timeframe and any special care that is needed. The prescription then goes to a medical transcriptionist, who enters it into the hospital computer system. In the central pharmacy, a pharmacists assistant prints the request and dispenses it into unit doses that are sent back to the ICU. In the morning, the medications are checked by a nurse, who stores them in individual drawers identied by bed number. The nursing aides prepare the medication and administer it to the patient, checking it against the prescription. All of these steps were checked for the existence of MEs.

Participants
Forty-four adults with medical and surgical diagnoses were studied. They represented all inpatients in the ICU during the 30-day research period (February to March, 2006).

Data collection
Three different strategies for detecting MEs were used: anonymous self-reports, staff interviews and a review of patient records. Anonymous self-report data were collected daily by the senior investigator from a box where voluntary reports were posted by the nursing staff. Staffs were encouraged, at the beginning of the investigation, to produce these reports and were assured that the reports would be kept anonymous. Whenever possible these reports were checked in the ICU. Staff interviews were conducted by a nurse-investigator (EB), who visited the ICU at least once daily and solicited ME reports from nurses, nursing aides, physicians, and medical transcriptionists (see below). All were encouraged to report any deviations detected or suspected from prescriptions or in delivering drugs and care. Review of patient prescriptions, the third strategy for detecting MEs, consisted of analysing all the patient records for evidence of errors. This was conducted daily by the nurseinvestigator. Validation of types of MEs Medication errors were classied based on the 12 types described by the American Society of Health-System Pharmacists (ASHP) (1993) taxonomy. As there was no previous report of validation of those types of MEs in Brazil, prior to this study we validated the taxonomy for local relevance with a group of 18 panelists involved in the medication system, including two former ICU patients, using the Delphi technique.

Ethical considerations
The study was approved by appropriate ethics and governance committees. The staff responsible for medical, nursing, and pharmacy teams in the ICU were informed of every step of the investigation and the nature of the research and asked to sign an informed consent form. In some instances, the nurse-investigator intervened in the medication system, alerting caregivers of potentially harmful situations that were detected while data were being collected.

Data analysis
Most of the data were described as both absolute and per cent gures. To compare the relative frequencies of MEs per day in the two groups (<7 days of ICU stay and more than 7 days) the MannWhitneyWilcoxon test for non-parametric distributions was applied using SPSS for Windows 95

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

1261

E. Bohomol et al.

(Version 8.0, SPSS Inc., Chicago, IL, USA) The level of statistical signicance adopted was 005 (a = 5%).

Types of errors
The types of MEs found in the ICU were also studied. Table 2 lists the denitions of the MEs types, according to the ASHP, and gives examples of errors detected during this study. Table 3 lists the types of MEs found and their frequencies. Omission error was the most frequent type, with 217 occurrences (711%), followed by wrong time error, which occurred 35 times (115%). There were no errors of the wrong drug-preparation error and wrong administration technique error types, but this probably reects the chosen methods of MEs detection rather than the actual error rate. The deteriorated drug error and compliance error types also were not detected in this series. The deteriorated drug error is probably absent because this particular institution delivers the drug in an individualized package. The compliance error rate is probably very low in the ICU, specically, due to the seriousness of the patients conditions, which require strict adherence to the medication prescribed, and the majority of patients are intubated, sedated and receiving i.v. medication.

Findings
In the 30-day period, we studied 44 patients with a mean ICU stay of 124 days. The patients ranged in age from 25 to 84 years, mean (SD ) 578 (169), median 58 years. The average number of patients in the ICU was 156 06 per day, which corresponds to 467 patient-days in 1 month. During the study period, the ICU had a 968% occupation rate and there were 11 deaths (25%). The period analysed compared well with the annual statistics of the ICU, which included a mean length of stay of 152 days, an occupation rate of 968% and a mortality rate of 23%. There were 305 occurrences of MEs in the period studied, with a mean of 69 occurrences per patient (SD = 68, median = 5) which corresponds to 653 events in 1000 patient-days. In this study, only four patients (92%) had no MEs; 21 (473%) had 15 MEs occurrences, 10 (228%) had 610 occurrences, ve (115%) had 1120 occurrences and 4 (92%) had more than 20 occurrences of MEs, including one with 25 MEs. Analysis of the MEs detection techniques revealed that staff interview was the most efcient, detecting 161 occurrences (528%), followed by review of prescriptions, with 125 occurrences detected (41%), and nally, anonymous selfreports, which revealed only 19 occurrences (62%). One question identied during the elaboration of the collecting protocol was if patients with longer stay in the ICU were more prone to MEs. As the reported annual average ICU stay was 152 days, we divided patients into two groups based on length of stay: <1 week and more than 1 week. These arbitrary groupings were chosen because 7 days corresponds approximately to half of the average ICU stay. We compared the number of MEs per day in the group with <1 week with the group with more than 1 week ICU stay. This showed that the group with the longer ICU stay had more MEs per day than the other group (Table 1).

Causes of MEs
The most plausible causes for the occurrence of MEs in our series are listed in Table 4. Lack of drug availability was the most common cause of MEs, responsible for 123 of occurrences (41%). This error occurred when the drug was absent from the central pharmacy, even if it was available in the stock building, which is located outside of the hospital. The stock building adheres to a very rigid time schedule, and the medication must be sent early in the morning. In addition, medications can only enter the central pharmacy in individualized units; even if available, the drugs cannot be sent in their original packages. The second most common cause of MEs (163%) was a stock and distribution problem. With this type of error, even though the drug was available in the central pharmacy, the request was not processed for various reasons (bureaucratic or other). Failure in the transcription of the prescription accounted for 11% of the reported MEs. This type of error occurs when the medical transcriptionist does not accurately transcribe the medication that the physician prescribes. A communication failure among services caused 8% of MEs. In these instances, institutional routines were not obeyed. These types of errors were particularly related to high-alert medications, such as psychotropic or sedation drugs that could only be requested using a handwritten special formulary. Failure to complete this special formulary

Table 1 Number of medication errors per day and length of stay

Number of medication errors/day Length of stay in intensive care unit Mean Less than 1 week 040 More than 1 week 073 Number of Minimum Maximum patients 150 180 18 26

SD

038 000 039 020

MannWhitneyWilcoxon test: P = 0003. 1262

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Medication errors in an intensive care unit

Table 2 Examples of types of medication errors found

Types Omission Denition Failure to administer an ordered dose to a patient before the next scheduled dose Examples According to the main action, there were omissions related to the following groups of drugs: antibiotic (252% of the omissions), gastric acid blockers (19%), anti-hypertensive (92%), intravenous anaesthetic (opioid and non-opioid) (52%), antiemetic (46%), anticoagulant (33%) The Delphi panelists concluded that this error happened when medication delivery occurred with more than 15 minutes after the scheduled time for drugs scheduled for every 4, 6, 8 or 12 hours, or more than 30 minutes for daily doses 100 vials of tramadol were prescribed instead of 100 mg; 25 capsules of hydrochlorothiazide were prescribed instead of 25 mg; ranitidine prescribed via nasogastric tube instead of intravenously

Wrong time

Administration of medication outside a predened time interval from its scheduled administration time

Prescribing

Improper dose

Incorrect drug selection, dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician; illegible prescriptions or medication orders that lead to errors that reached the patient Administration of a dose that is greater than or less than the amount ordered by the prescriber, or administration of duplicate doses to the patient

Wrong dosage form

Administration of a drug product in a different dosage form than ordered by the prescriber

Unauthorized drug error Monitoring

Other

Administration of medication not authorized by a legitimate prescriber Failure to review a prescribed regimen for appropriateness and problems, or failure to use appropriate clinical or laboratory data for assessment of patient response to prescribed therapy Any medication errors that does not fall into one of the above predened categories

Streptomycin intended to be prescribed every other day had been already prescribed the day before; administration of hydrocortisone every 12 hours when it was prescribed every 24 hours; 80 mg gentamicin administered instead of the prescribed 120 mg Ranitidine, by an i.v. route was prescribed but an oral form was requested from the pharmacy; heparin prescribed i.v. (ask) was solicited into the subcutaneous form (ampoule) from the pharmacy 30 ampoules of dobutamine were solicited but not prescribed Ampicillin + sulbactam were recorded as to be in the 9th day of use but were unavailable in the institution for the previous 8 days

Drugs delivered and not checked, or not given but not registered as so in the nursing record

Table 3 Types of medication errors in the intensive care unit

Type Omission error Wrong time error Prescribing error Improper dose error Wrong dosage-form error Unauthorized drug error Monitoring error Wrong drug preparation error Wrong administration technique error Deteriorated drug error Compliance error Other medication error Total n (%) 217 35 14 5 2 1 1 30 305 (711) (115) (46) (17) (07) (03) (03)

Table 4 Causes of medication errors in the intensive care unit

Causes Drug not available at the institution Problems in stock or distribution in the pharmacy Failure in transcription of the prescription to pharmacy Communication failure among services Problems related to prescription Slips, memory lapses, and failure to check medication Work overload and disruption Others Infusion pump problems Failure in following protocols Total n < 305 due to incomplete data. n (%) 123 (410) 49 (163) 33 (110) 24 (80) 21 (70) 20 (66) 15 11 2 2 300 (50) (37) (07) (07) (1000)

(98) (1000)

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

1263

E. Bohomol et al.

often prevented the nurse and pharmacist from processing the request. Finally, problems related to prescription were responsible for 7% of MEs. These generally occurred when handwritten prescriptions were illegible or unclear.

Consequences of MEs
During the investigation period, we detected 157 incidents related to MEs with consequences for patients (515%). These consequences represent a subjective evaluation by the professionals involved in the patients care. In 58 occurrences (369%), the error was intercepted before reaching the patient. These are known as latent or potential errors, and it is relevant that the nurse was, almost always (47 instances, 81%), the professional actively involved in the detection. In another 58 instances (369%), the occurrence was labelled by the interviewee as occurring without affecting the patients condition. In 31 instances (198%), the consequences, without any change in the patients clinical status, led to an increase in monitoring/observing the patients status. This was dened as an increased number of visits to the patient by ICU staff or more careful observation of vital signs and cardiac monitoring. In 10 (64%) of the occurrences, an increased need for laboratory examinations or a change in the vital signs was detected. In the general ICU, the number of laboratory examinations is very high, making it difcult to detect any increase attributable to MEs. However, in these reported instances, all patients had changes in arterial blood pressure as well as episodes of agitation. In our study, no consequences were reported as entailing need of additional treatment or increased length of ICU stay, need for more intensive treatment or invasive procedure or a fatal consequence.

Discussion
Study limitations
Some of the limitations of this study originate from the use of only three methods of error detection. This could be improved in future studies by using other methods of sampling, such as direct observation and the trigger tool technique. Another issue was the limited collaboration from pharmacists and medical staff, as the MEs detected came almost exclusively from the nursing team.

and length of stay in the unit were very high, even by Brazilian standards. The census of ICUs conducted by the Brazilian Association of Intensive Care (AMIB 2004) suggests that the ideal occupation index is approximately 85%. A mortality index of 185% and mean stay of 6 days are expected, according to the prole of the ICUs analysed (AMIB 2004). All of those parameters were exceeded in the ICU studied. One of the important ndings of the present study was the statistically signicant increase in numbers of MEs per day in those with an ICU stay longer rather than <7 days. This nding had not previously been reported. The incidence of MEs in the ICU under study was extremely high when compared to that of other ICUs in Brazil (Toffoletto & Padilha 2006), or worldwide (Cullen et al. 1997, Calabrese et al. 2001, Kopp et al. 2006). As the omission error is extremely frequent, the prevalence of MEs probably derives from particular problems of the institution in dealing with the requisition and distribution of medications. There is a consensus in the literature that anonymous reports are the least accurate method for detection of adverse events (Flynn et al. 2002) and in our study this afrmation was conrmed, as only 62% of MEs were detected by this method. Despite the large number of MEs detected, we suggest that, if other techniques of detection had been employed, even larger numbers of MEs would have been exposed; direct observation would allow the detection of MEs related to time-frame compliance, drug preparation and delivery technique (Flynn & Barker 1999, Flynn et al. 2002). With the trigger tool technique, problems related to drug indication, interaction or monitoring could be observed (Rozich et al. 2003, Grifn & Resar 2007). These techniques could also reveal other structural and procedural situations in the unit that should be considered when measures to improve the system are proposed. Types of errors Of the 12 types of errors listed in the ASHP classication, eight were encountered in this investigation. Omission error requires special attention, as patients in ICU are extremely ill, unstable, and dependent on adequate and timely drug therapy. This type of error, in this critical situation, threatens the success of treatment by not allowing the administration of an antibiotic, anticoagulant, antihypertensive or another crucial drug prescribed. Omission error was the most frequently detected error and deserves detailed study as understanding it will permit the implementation of changes to improve and correct an important part of the medication system. In the present

Discussion of ndings
In this research, we studied a population of extremely ill patients in the ICU. The ICU occupation index, mortality rate
1264

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Medication errors in an intensive care unit

investigation, the primary causes of omission errors were lack of the medication in the pharmacy, missing stocks, failures in distribution, excessive bureaucratization of the system and transcription mistakes. These straightforward errors are relatively easy to address via administrative measures. Omission errors, together with wrong time errors, incorrect dose errors, wrong drug administered errors and wrong speed of infusion errors, also appear in several studies as the most important types of MEs (Girotti et al. 1987, Calabrese et al. 2001, Kopp et al. 2006). The types of errors found in the present study reect the reality of hospital organizations in both developed and undeveloped countries, independent of the resources available or the working conditions. In Brazil, there have been very few published reports concerning MEs in ICUs. The few reports that exist suggest that omission errors, wrong drug administration and wrong dose administration are the most frequent errors (Toffoletto & Padilha 2006). Causes of MEs The two causes most frequently identied as being responsible for errors, drug not available at the institution and problems in stock or distribution in the pharmacy, accounted for 573% of all of the MEs. They are related to the classic Structure-Process-Outcome triad (Donabedian 1980) in healthcare management systems, as components of the Structure (drugs not available in the pharmacy) and Process (stock and distribution problems in the pharmacy) lead to consequences in the Outcome (potential risk of defective treatment). As the medication system is multiprofessional, it requires collaboration between professionals from all areas involved in the problem. More specically, hospital managers and pharmacists are responsible for the changes that should be implemented to create a new medication ow chart, from acquisition to dispensing. Pharmacists need to be more involved in the analyses, decision-making, and improvements to the system (JCAHO 2001) and are important agents of detection of MEs (Nichols et al. 2008). Failure in the transcription of the prescription error also deserves attention. This type of error increases the workload of healthcare professionals and exposes patients to unnecessary risk. This type of error is also commonly reported in the literature, accounting for about 12% of all MEs (Leape et al. 1995). Therefore, it is extremely important that the prescription be reconciled with the transcribed prescription, and this is the responsibility of the pharmacist. Communication failure among services error calls attention to the routines in the ICU itself. Improved routines must

be discussed, simulated and followed by all of the professionals involved: nursing staff, physicians and pharmacists. Each time the system fails, it must be reviewed by all professionals, and the routines should be adjusted accordingly (Grant 1999). Problems related to prescription errors need to be analysed to prevent MEs. These errors are attributed to the medical team, but every professional has an obligation to collaborate in the detection of present or potential errors. Illegible handwriting, incomplete information, use of abbreviations, mistakes in weight, volumes, or units prescribed, use of decimals in prescribing, mistakes in the medication name, and lack of awareness of possible negative drug interactions are all probable causes of these types of errors (Schneider & Gift 1998, Cohen 1999, Flynn & Barker 1999). All of these situations were detected in the present study. In general, studies have shown that the most common causes of MEs in ICUs include: lack of knowledge on the part of physicians and nursing staff about the actions of the drug prescribed; incomplete, illegible or verbal orders in prescriptions; lack of drug dispensing and preparation protocols; improper use of i.v. infusion pumps; incorrect transcription of the prescription; and work overload in nursing (Cullen et al. 1997, Flynn & Barker 1999). Some researchers have also found large numbers of memory slips and failures, incorrect drug identication, violations of protocols, and problems with the stocking and distribution of medications (Girotti et al. 1987). Consequences of MEs According to Schneider & Gift (1998), the analysis of data concerning the consequences of MEs to patients can result in a system for grading the severity of MEs, which helps to identify those that need to be addressed immediately. In this study, it was particularly difcult to grade the severity of the consequences because the patients clinical status was severe and there was an important lack of knowledge about the interactions of medications used. Therefore, healthcare professionals may have difculty linking MEs with any specic change in a patients clinical condition. The impact of consequences detected in our study matches that of reports in the literature, which indicate that the most common MEs usually did not worsen patient status (Flaatten & Hevroy 1999, Calabrese et al. 2001). Even the worst situations required only an increase in attention/monitoring (Tissot et al. 1999, Calabrese et al. 2001). Overall, fatalities seldom occur as consequences MEs (Flaatten and Hevroy 1999, Kopp et al. 2006), and, indeed, we observed no fatalities directly attributable by interviewees to MEs.
1265

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

E. Bohomol et al.

What is already known about this topic

Medication errors are a common problem in hospitals around the world and most are preventable. The causes of medication errors must be studied for each institution because preventive actions must be individualized. A culture with an emphasis on quality care, with the involvement of managers, physicians, pharmacists and nurses could reduce the incidence of medication errors.

What this paper adds

Use of a single method, for example, an anonymous selfreport form, results in underreporting of medication errors. In this intensive care unit, patients with a stay longer than 1 week had more medication errors per day than those with a stay of <1 week. Multidisciplinary collaboration is required to gain a fuller picture of medication errors occurring within hospitals, and to address their causes.

Implications for practice and/or policy

The higher rank administration must be involved supporting the development of a patient safety culture. Utilization of tools to detect medications errors should be encouraged in every hospital once they are responsible for the disclosure of hazardous situations. Having a pharmacist as a member of a multidisciplinary team is imperative for preventing a large number of different medication errors. Although no fatalities or severe consequences were identied by the interviewees, ICU length of stay and mortality were above the values predicted for analogous ICUs and warrant more careful analysis. Specic quality indicators for ICU could perhaps be used for better monitoring of the quality of care. (Vos et al. 2007). Otherwise, the risk of major consequences from MEs is always present and justies taking extreme measures to prevent them.

numbers of drugs. The information acquired in a study like this must be used to address corrective and preventive actions. These may be obtained through a continuous and pro-active search for quality, with full collaboration from high-level institutional managers and all professionals involved in patient care. Our results suggest that healthcare managers should promote the following changes in their systems: (1) create a culture of patient safety, with the involvement of every professional, including high-level managers; (2) stimulate staff leaders to be vigilant to the problem of MEs in order to devise and promote the necessary changes to deal with the errors; (3) completely revise the medication system, with the participation of a multidisciplinary team, with special attention to pharmacists role; (4) use quality control tools and health indicators to monitor and continuously revise the processes and (5) manage adverse events through monitoring of patient consequences. Clearly, the implementation of some of these measures depends on the nancial resources of the institution, but most of the changes can be accomplished through management decisions and alterations in institutional policies. Patient safety is not the responsibility of any one person or professional category, but rather it involves every person in the institution. Any costs associated with changes in the medication system are outweighed by the benets of safer treatment and improved patient satisfaction.

Acknowledgement
We extend our thanks to Professor Manoel Carlos Prieto Velhote, Paediatric Surgeon, University of Sao Paulo Medical School, for help in the translation and correction of this article.

Funding
This research received no specic grant from any funding agency in the public, commercial or not-for-prot sectors.

Conict of interest
No conict of interest has been declared by the authors.

Conclusion
Medication errors occur in every context that uses a medication system; the ICU is not an exception. Indeed, ICUs are perhaps exposed to a larger number of MEs as they often operate under stressful conditions, involving numerous emergency procedures, and the use of large
1266

Author contributions
EB and LHR were responsible for the study conception and design, and provided statistical expertise. EB performed the data collection and was responsible for the drafting of the manuscript. EB, LHR and MD performed the data analysis and made critical revisions to the paper for important

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Medication errors in an intensive care unit care unit. Heart & Lung: the Journal of Critical Care 16, 449 453. Grant S.M. (1999) Whos to blame for tragic error? The American Journal of Nursing 99, 9. Griffin F.A. & Resar R.K. IHI Global Trigger Tool for measuring adverse events. IHI Innovation Series white paper. Institute for Healthcare Improvement, Cambridge, MA, 2007. Retrieved from http://www.ihi.org/IHI/Results/WhitePapers/IHIGlobalTrigger ToolWhitePaper.htm on 22 April 2007. JCAHO (2001) Preventing medication errors: strategies for pharmacists Joint Commission on Accreditation of Healthcare Organizations. Joint Commission Resources, Oakbrook Terrace, IL. Kohn L.T., Corrigan J.M. & Donaldson M.S. (eds) (2000) To Err Is Human: Building a Safer Health System. National Academy Press, Washington, DC. Kopp B.J., Erstad B.L., Allen M.E., Theodorou A.A. & Priestley G. (2006) Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Critical Care Medicine 34, 415425. Leape L.L., Bates D.W., Cullen D.J., Cooper J., Demonaco H.J., Gallivan T., Hallisey R., Ives J., Laird N., Laffel G., Nemeskal R, Petersen L.A., Porter K., Servi D., Shea B.F., Small S.D., Sweitzer R.J., Thompson T. & Vliet M.V. (1995) Systems analysis of adverse drug events. ADE Prevention Study Group. Journal of the American Medical Association 274, 3543. Nichols P., Copeland T., Craib I.A., Hopkins P. & Bruce D.G. (2008) Learning from error: identifying contributory causes of medication errors in an Australian hospital. The Medical Journal of Australia 188, 276279. ONA (2008) Instituicoes Acreditadas. Instituicoes Hospitalares. Organizacao Nacional de Acreditacao. Retrieved from http:// www.ona.org.br on 1 November 2008. Rozich J.D., Haraden C.R. & Resar R.K. (2003) Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Quality & Safety in Health Care 12, 194200. Schneider P.J. & Gift M. (1998). Measuring and monitoring the performance of the medication use system. In Medication Use: a Systems Approach to Reducing Errors (Joint Commission on Accreditation of Healthcare Organizations eds), Joint Commission Resources. Oakbrook Terrace, IL, pp. 1937. Tissot E., Cornette C., Demoly P., Jacquet M., Barale F. & Capellier G. (1999) Medication errors at the administration stage in an intensive care unit. Intensive Care Medicine 25, 353359. Toffoletto M.C. & Padilha K.G. (2006) Consequencias dos erros de medicacao em unidades de terapia intensiva e semi-intensiva. Revista da Escola de Enfermagem da U S P 40, 247252. Vos M., Graafmans W., Keesman E., Westert G. & Voort P.H.J. (2007) Quality measurement at intensive care units: which indicators should we use. Journal of Critical Care 22, 267274.

intellectual content, also provided administrative, technical or material support. LHR and MD supervised the study.

References
AMIB (2004) Anuario Brasileiro de UTIs.Associacao de Medicina Intensiva Brasileira. MWS Design, Sao Paulo. American Society of Health-System Pharmacists (ASHP) (1993) Guidelines on preventing medication errors in hospitals. American Journal of Hospital Pharmacy 50, 305314. Bates D.W., Cullen D.J., Laird N., Petersen L.A., Small S.D., Servi D., Laffel G., Sweitzer B.J., Shea B.F., Hallisey R., Vliet M.V., Nemeskal R. & Leape L.L. (1995) Incidence of adverse drug events and potential adverse drug events. Implications for prevention. Journal of the American Medical Association 274, 2934. Bates D.W., Spell N., Cullen D.J., Burdick E., Laird N., Petersen L.A., Small S.D., Sweitzer B.J. & Leape L.L. (1997) The costs of adverse drug events in hospitalized patients. Journal of the American Medical Association 277, 307311. Calabrese A.D., Erstad B.L., Brandl K., Barletta J.F., Kane S.L. & Sherman D.S. (2001) Medication administration errors in adult patients in the ICU. Intensive Care Medicine 27, 15921598. CBA (2007) Acreditacao. Instituicoes Acreditadas no Brasil. Consorcio Brasileiro de Acreditacao, Retrieved from http://www.cbacred. org.br/front/instit_acreditadas_brasil.php on 1 December 2007. Cohen M.R. (1999) Preventing dispensing errors. In Medication Errors: Causes, Prevention, and Risk Management (Cohen M.R. ed), Jones & Bartlett Publishers, Sudbury, MA, pp. 9.119. Cullen D.J., Sweitzer B.J., Bates D.W., Burdick E., Edmondson A. & Leape L.L. (1997) Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Critical Care Medicine 25, 12891297. Donabedian A. (1980) Basic approaches to assessment: structure, process and outcome. In Exploration in Quality Assessment and Monitoring (Donabedian A. ed), Health Administration Press, Ann Arbor, MI, pp. 77125. Flaatten H. & Hevroy O. (1999) Errors in the intensive care unit (ICU). Experiences with an anonymous registration. Acta Anaesthesiologica Scandinavica 43, 614617. Flynn E.A. & Barker K.N. (1999) Medication errors research. In Medication Errors: Causes, Prevention and Risk Management (Cohen M.R. ed), Jones & Bartlett Publishers, Sudbury, MA, pp. 6.125. Flynn E.A., Barker K.N., Pepper G.A., Bates D.W. & Mikeal R.L. (2002) Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. American Journal of Health-System Pharmacy 59, 436446. Girotti M.J., Garrick C., Tierney M.G., Chesnick K. & Brown S.J. (1987) Medication administration errors in an adult intensive

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientic journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. For further information, please visit the journal web-site: http://www.journalofadvancednursing.com

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd

1267