Comparison of Intensive Care Unit Medication Errors Reported to the United States’ MedMarx and the United Kingdom’s National Reporting and Learning System: A Cross-sectional Study

First Published May 8, 2013 Research Article Find in PubMed

Authors

, MD1
 
University of Michigan School of Medicine, Ann Arbor, MI
by this author
, , PhD2
 
Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
by this author
, , PharmD, BCPS3
 
The Johns Hopkins Hospital, Baltimore, MD
by this author
,
4
 
University Health Board, Glan Clwyd Hospital, Denbighshire, UK
by this author
, 56
 
Centre for Population Health Sciences, Edinburgh, UK
 
National Patient Safety Agency, London, UK
by this author
, 6
 
National Patient Safety Agency, London, UK
by this author
, , MD, PhD, FCCM27
 
Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
 
Bloomberg School of Public Health, Baltimore, MD
by this author
, , MD8
 
National Health Service Foundation Trust, London, UK
by this author
, , MD, PhD2
 
Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
by this author
...
First Published Online: May 8, 2013

The objective was to compare the characteristics of medication errors reported to 2 national error reporting systems by conducting a cross-sectional analysis of errors reported from adult intensive care units to the UK National Reporting and Learning System and the US MedMarx system. Outcome measures were error types, severity of patient harm, stage of medication process, and involved medications. The authors analyzed 2837 UK error reports and 56 368 US reports. Differences were observed between UK and US errors for wrong dose (44% vs 29%), omitted dose (8.6% vs 27%), and stage of medication process (prescribing: 14% vs 49%; administration: 71% vs 42%). Moderate/severe harm or death was reported in 4.9% of UK versus 3.4% of US errors. Gentamicin was cited in 7.4% of the UK versus 0.7% of the US reports (odds ratio = 9.25). There were differences in the types of errors reported and the medications most often involved. These differences warrant further examination.

1. Leape, LL, Brennan, TA, Laird, N, The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-384.
Google Scholar | Crossref | Medline | ISI
2. Brennan, TA, Leape, LL, Laird, NM, Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376.
Google Scholar | Crossref | Medline | ISI
3. Bond, CA, Raehl, CL, Franke, T. Medication errors in United States hospitals. Pharmacotherapy. 2001;21:1023-1036.
Google Scholar | Crossref | Medline
4. Pronovost, PJ, Thompson, DA, Holzmueller, CG, Toward learning from patient safety reporting systems. J Crit Care. 2006;21:305-315.
Google Scholar | Crossref | Medline | ISI
5. Aviation safety reporting system . Program briefing. http://asrs.arc.nasa.gov/overview/summary.html. Accessed January 2, 2013.
Google Scholar
6. National fire fighter near-miss reporting system . Frequently asked questions. http://www.firefighternearmiss.com/index.php/faq-page. Accessed January 2, 2013.
Google Scholar
7. Pham, JC, Story, JL, Hicks, RW, National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med. 2011;40:485-492.
Google Scholar | Crossref | Medline | ISI
8. Dean, BS, Allan, EL, Barber, ND, Barker, KN. Comparison of medication errors in an American and a British hospital. Am J Health Syst Pharm. 1995;52:2543-2549.
Google Scholar | Crossref | Medline | ISI
9. Wirtz, V, Taxis, K, Barber, ND. An observational study of intravenous medication errors in the United Kingdom and in Germany. Pharm World Sci. 2003;25:104-111.
Google Scholar | Crossref | Medline
10. Cousins, DH, Sabatier, B, Begue, D, Schmitt, C, Hoppe-Tichy, T. Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care. 2005;14:190-195.
Google Scholar | Crossref | Medline
11. Cullen, DJ, Sweitzer, BJ, Bates, DW, Burdick, R, Edmondson, A, Leape, LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997;25:1289-1297.
Google Scholar | Crossref | Medline | ISI
12. Pham, JC, Colantuoni, E, Dominici, F, The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems. Qual Saf Health Care. 2010;19:440-445.
Google Scholar | Medline
13. Martinez, EA, Shore, A, Colantuoni, E, Cardiac surgery errors: results from the UK National Reporting and Learning System. Int J Qual Health Care. 2011;23:151-158.
Google Scholar | Crossref | Medline
14. National Patient Safety Agency . What is a patient safety incident? http://www.npsa.nhs.uk/nrls/reporting/what-is-a-patient-safety-incident/. Accessed January 2, 2013.
Google Scholar
15. Pham, JC, Andrawis, M, Shore, AD, Fahey, M, Morlock, L, Pronovost, PJ. Are temporary staff associated with more severe emergency department medication errors? J Healthc Qual. 2011;33:9-18.
Google Scholar | Crossref | Medline
16. US Department of Veterans Affairs . National formulary: Veterans Affairs therapeutic classification. http://www.pbm.va.gov/NationalFormulary.aspx. Accessed January 2, 2013.
Google Scholar
17. Valentin, A, Capuzzo, M, Guidet, B, Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med. 2006;32:1591-1598.
Google Scholar | Crossref | Medline | ISI
18. Calabrese, AD, Erstad, BL, Brandl, K, Barletta, JF, Kane, SL, Sherman, DS. Medication administration errors in adult patients in the ICU. Intensive Care Med. 2001;27:1592-1598.
Google Scholar | Crossref | Medline | ISI
19. Kane-Gill, SL, Jacobi, J, Rothschild, JM. Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med. 2010;38(6, suppl):S83-S89.
Google Scholar | Crossref | Medline
20. Benkirane, RR, Abouqal, R, Haimeur, CC, Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study. J Patient Saf. 2009;5:16-22.
Google Scholar | Crossref | Medline
21. Gallagher, TH, Waterman, AD, Ebers, AG, Fraser, VJ, Levinson, W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-1007.
Google Scholar | Crossref | Medline | ISI
22. Panesar, SS, Cleary, K, Sheikh, A. Reflections on the National Patient Safety Agency’s database of medical errors. J R Soc Med. 2009;102:256-258.
Google Scholar | SAGE Journals
23. Sarvadikar, A, Prescott, G, Williams, D. Attitudes to reporting medication error among differing healthcare professionals. Eur J Clin Pharmacol. 2010;66:843-853.
Google Scholar | Crossref | Medline | ISI
24. Neale, G, Vincent, C, Darzi, SA. The problem of engaging hospital doctors in promoting safety and quality in clinical care. J R Soc Promot Health. 2007;127:87-94.
Google Scholar | SAGE Journals
25. Capuzzo, M, Nawfal, I, Campi, M, Valpondi, V, Verri, M, Alvisi, R. Reporting of unintended events in an intensive care unit: comparison between staff and observer. BMC Emerg Med. 2005;5:3.
Google Scholar | Crossref | Medline
26. Wald, ML . Fatal airplane crashes drop 65%. New York Times. October 1, 2007:C1.
Google Scholar
27. Keeling, P, Scales, K, Keeling, S, Borthwick, M. Towards IV drug standardization in critical care. Br J Nurs. 2010;19:S30-S33.
Google Scholar | Crossref | Medline
28. Frey, B, Buettiker, V, Hug, MI, Does critical incident reporting contribute to medication error prevention? Eur J Pediatr. 2002;161:594-599.
Google Scholar | Crossref | Medline | ISI

Access content

To read the fulltext, please use one of the options below to sign in or purchase access.
  • Access Options

    My Account

    Welcome
    You do not have access to this content.

    Chinese Institutions / 中国用户

    Click the button below for the full-text content

    请点击以下获取该全文

    Institutional Login

    Purchase Content

    24 hours online access to download content

    Added to Cart

    Cart is full

    There is currently no price available for this item in your region.

    Research off-campus without worrying about access issues. Find out about Lean Library here


Purchase

AJM-article-ppv for $41.50