Background Medication errors occur frequently in intensive care units (ICU). Voluntarily reported medication errors form an easily available source of information. Objective This study aimed to characterize prescribing, monitoring and medication transfer errors that were voluntarily reported in the ICU, in order to reveal medication safety issues. Setting This retrospective data analysis study included reports of medication errors from eleven Dutch ICU’s from January 2016 to December 2017. Method We used data extractions from the incident reporting systems of the participating ICU’s. The reports were transferred into one database and categorized into type of error, cause, medication (groups), and patient harm. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories. Based on the analysis, ICU medication safety issues were revealed. Main outcome measure The main outcome measure was the proportion of prescribing, monitoring and medication transfer error reports. Results Prescribing errors were reported most frequently (n = 233, 33%), followed by medication transfer errors (n = 85, 12%) and monitoring errors (n = 27, 4%). Other findings were: medication transfer errors frequently caused serious harm, especially the omission of home medication involving the central nervous system and proton pump inhibitors; omissions and dosing errors occurred most frequently; protocol problems caused a quarter of the medication errors; and medications needing blood level monitoring (e.g. tacrolimus, vancomycin, heparin and insulin) were frequently involved. Conclusion This analysis of voluntarily reported prescribing, monitoring and medication transfer errors warrants several improvement measures in these processes, which may help to increase medication safety in the ICU.

Incident reporting system, Intensive care unit, Medication error, Medication safety, Patient safety, The Netherlands, Voluntarily reports,
International Journal of Clinical Pharmacy
Department of Pharmacy

Bosma, B.E, Hunfeld, N.G.M, Roobol-Meuwese, E. (E.), Dijkstra, T. (T.), Coenradie, S.M. (S. M.), Blenke, A. (A.), … van den Bemt, P.M.L.A. (2020). Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands. International Journal of Clinical Pharmacy. doi:10.1007/s11096-020-01101-5