Medication errors and risk areas in a critical care unit

The aim of this study was to identify the main medication errors, their causality and the highest risk areas in critical care.A descriptive, longitudinal and retrospective study.We performed a systematic analysis of the prescription, transcription and administration records of 2,634 dose units of medications that were administered to a total of 87 critically ill patients during 2018.Final results have shown important medication errors and a high number of significant drug interactions; prescription phase had the highest mistake rate (71%) and cause of errors (68%); transcription stage had a more variable error typology. A significant correlation was observed between the presence of causes and contributing factors to error during the prescription and the commission of errors during the nurse transcription, being the main risk areas the time of antibiotic administration, dilution errors, concentration and speed of administration of high-risk medications and the technique used for nasogastric tube drug administration.In critical care, an intolerable number of medication errors are still committed, placing the origin of many of them in the causality and contributing factors identified in the prescription stage.The origin of many of the medication errors and most interactions is in the prescription stage, being the nurse transcription (nurse intervention) in an important filter that prevents a considerable number of errors from finally reaching the patient. The schedule of administration of time-dependent antibiotics, high-risk medications and the technique of administering medications through a nasogastric tube are important risk areas for the commission of medication errors.目标: 这项研究旨在确定重症监护的主要药物错误,其因果关系和最高风险领域。 设计: 描述性、纵向和回顾性研究。 方法: 我们对2018年共87名危重病患者服用的2634个剂量单位的药物处方、誊写处方和给药记录进行系统分析。 结果: 最终结果显示存在重大的药物错误和极为明显的药物相互作用;处方阶段的错误率(71%)和错误原因(68%)最多;誊写阶段的错误类型更多变。处方过程中出现错误的原因和促成因素与护士誊写过程中出现的错误之间存在显著的相关性,主要的风险领域包括抗生素的使用时间、稀释错误,高风险药物的给药浓度和速度以及用于鼻胃管给药的技术问题。 结论: 在危重病护理中,依旧存在难以容忍的药物错误,许多错误的根源在于处方阶段识别的因果关系和促成因素。 影响: 许多药物错误和大多数交互作用的根源都在处方阶段,护士誊写(护士干预)是一个重要的筛选手段,可防范最终出现在患者身上的大量错误。时间依赖性抗生素、高风险药物的给药计划以及通过鼻胃管给药的技术是导致药物错误的重要风险领域。.