• Andreas Valentin, Maurizia Capuzzo, Bertrand Guidet, Rui Moreno, Barbara Metnitz, Peter Bauer, Philipp Metnitz, Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM), and Sentinel Events Evaluation (SEE) Study Investigators.
• Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria. andreas.valentin@meduniwien.ac.at
• BMJ. 2009 Jan 1;338:b814.

ObjectiveTo assess on a multinational level the frequency, characteristics, contributing factors, and preventive measures of administration errors in parenteral medication in intensive care units.DesignObservational, prospective, 24 hour cross sectional study with self reporting by staff.Setting113 intensive care units in 27 countries.Participants1328 adults in intensive care.Main Outcome MeasuresNumber of errors; impact of errors; distribution of error characteristics; distribution of contributing and preventive factors.Results861 errors affecting 441 patients were reported: 74.5 (95% confidence interval 69.5 to 79.4) events per 100 patient days. Three quarters of the errors were classified as errors of omission. Twelve patients (0.9% of the study population) experienced permanent harm or died because of medication errors at the administration stage. In a multiple logistic regression with patients as the unit of analysis, odds ratios for the occurrence of at least one parenteral medication error were raised for number of organ failures (odds ratio per increase of one organ failure: 1.19, 95% confidence interval 1.05 to 1.34); use of any intravenous medication (yes v no: 2.73, 1.39 to 5.36); number of parenteral administrations (per increase of one parenteral administration: 1.06, 1.04 to 1.08); typical interventions in patients in intensive care (yes v no: 1.50, 1.14 to 1.96); larger intensive care unit (per increase of one bed: 1.01, 1.00 to 1.02); number of patients per nurse (per increase of one patient: 1.30, 1.03 to 1.64); and occupancy rate (per 10% increase: 1.03, 1.00 to 1.05). Odds ratios for the occurrence of parenteral medication errors were decreased for presence of basic monitoring (yes v no: 0.19, 0.07 to 0.49); an existing critical incident reporting system (yes v no: 0.69, 0.53 to 0.90); an established routine of checks at nurses' shift change (yes v no: 0.68, 0.52 to 0.90); and an increased ratio of patient turnover to the size of the unit (per increase of one patient: 0.73, 0.57 to 0.93).ConclusionsParenteral medication errors at the administration stage are common and a serious safety problem in intensive care units. With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks can reduce the risk for such errors.

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