Background
Methods
Study design
Key concept | Definition |
---|---|
Medication error (ME) | ‘Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer’ [23]. Both ME reports that occurred to the patient and near misses intercepted before reaching the patient were included. The study sample did not include adverse drug reactions from an appropriate medication management and use (MMU) process [24] |
Anatomical Therapeutic Chemical (ATC) Classification System | In the ATC classification system, drugs are divided into 14 main groups and four sub-levels depending on the target organ or group of organs and their chemical, pharmacological and therapeutic properties [25] |
High-alert medications | High-alert medications are drugs with a heightened risk of causing significant patient harm when used in error [9]. Although mistakes may or may not be more common with these drugs, the consequences of an error are usually more devastating to patients |
Study setting
Data collection and processing
Descriptive quantitative analysis
Statistical analysis
Research ethics
Results
Characteristics of the ME reports comprising high-alert medications
High-alert medications involved in ME reports
High-alert medication | Administration route | n (%) |
---|---|---|
Parenteral nutrition preparations | IV | 130 (14.9) |
Hypertonic sodium chloride (greater than 0.9%) | IH a, IV, PO a | 93 (10.7) |
Potassium chloride concentrate | IV, PO a | 66 (7.6) |
Morphine | IV, PO | 47 (5.4) |
Heparin | IA, IV | 43 (4.9) |
Oxycodone | IM, IV, PO | 42 (4.8) |
Vincristine | IV | 33 (3.8) |
Fentanyl | IV, SL | 28 (3.2) |
Methotrexate | IV, IT, PO | 27 (3.1) |
Enoxaparin | SC | 26 (3.0) |
Cytarabine | IV, IT | 23 (2.6) |
Lipid emulsion | IV | 21 (2.4) |
Dopamine | IV | 18 (2.1) |
Milrinone | IV | 18 (2.1) |
Midazolam | IV, PO a, buccal | 17 (1.9) |
Liposomal amphotericin B | IV | 16 (1.8) |
Insulin Aspart | IV, SC | 14 (1.6) |
Hypertonic dextrose (20% or greater) | IV, PO a | 14 (1.6) |
Norepinephrine | IV | 12 (1.4) |
Epinephrine | IM, IV, local anaesthesia a | 11 (1.3) |
Insulin (human, biosynthetic) | IV | 11 (1.3) |
Propofol | IV | 10 (1.1) |
Doxorubicin | IV | 9 (1.0) |
Potassium phosphates concentrate | IV | 9 (1.0) |
Dexmedetomidine | IV, IN a | 8 (0.9) |
Mercaptopurine | PO | 8 (0.9) |
Pegaspargase | IM, IV | 8 (0.9) |
Tramadol | IV, PO | 8 (0.9) |
Amino-acid infusion | IV | 7 (0.8) |
Diazepam | IV, PO | 7 (0.8) |
Insulin Detemir | SC | 6 (0.7) |
Esketamine | IV, PO a | 6 (0.7) |
Levosimendan | IV | 6 (0.7) |
Lorazepam | IV, PO | 6 (0.7) |
Others b | various | 64 (7.3) |
Total | 872 (100.0) |
ATC group | Medications | n (%) |
---|---|---|
Blood substitutes and perfusion solutions (B05) | 345 (39.6) | |
IV solutions (B05B) | PN, lipid emulsion, hypertonic dextrose (20% or greater), amino acids | 172 (19.7) |
IV solution additives (B05X) | Hypertonic sodium chloride (> 0.9%), potassium chloridea, potassium phosphatesa, magnesium sulfatea | 170 (19.5) |
Peritoneal dialytics (B05D) | Bicavera® | 2 (0.2) |
Hemodialytics and hemofiltrates (B05Z) | Prismocal® | 1 (0.1) |
Antineoplastic agents (L01) | 139 (15.9) | |
Antimetabolites (L01B) | Cytarabine, mercaptopurine, thioguanine, azacitidine, fludarabine, clofarabine, methotrexate (IV) | 63 (7.2) |
Plant alkaloids and other natural products (L01C) | Vincristine, vinblastine, etoposide | 39 (4.5) |
Cytotoxic antibiotics and related substances (L01D) | Doxorubicin, daunorubicin, dactinomycin, idarubicin | 17 (1.9) |
Other antineoplastic agents (L01X) | Pegaspargase, carboplatin, tretinoin, asparaginase Erwinia, cisplatin | 14 (1.6) |
Alkylating agents (L01A) | Treosulfan, busulfan, cyclophosphamide, temozolomide | 5 (0.6) |
Protein kinase inhibitors (L01E) | Selumetinib | 1 (0.1) |
Analgesics (N02) | 98 (11.2) | |
Opioids (N02A) | Fentanyl (SL), morphine, oxycodone, tramadol | 98 (11.2) |
Antithrombotic agents (B01) | 75 (8.6) | |
Antithrombotic agents (B01A) | Heparin, enoxaparin, warfarin, urokinase, antithrombin | 75 (8.6) |
Cardiac therapy (C01) | 68 (7.9) | |
Cardiac stimulants excl. cardiac glycosides (C01C) | Dopamine, milrinone, norepinephrine, epinephrine, levosimendan | 65 (7.5) |
Antiarrhythmics, class I and III (C01B) | Amiodarone | 3 (0.3) |
Other cardiac preparations (C01E) | Adenosine | 1 (0.1) |
Anesthetics (N01) | 48 (5.5) | |
Anaesthetics, general (N01A) | Propofol, esketamine, ketamine, thiopental, fentanyl (IV) | 45 (5.2) |
Anaesthetics, local (N01B) | Ropivacaine | 3 (0.3) |
Psycholeptics (N05) | 39 (4.5) | |
Hypnotics and sedatives (N05C) | Midazolam, dexmedetomidine | 25 (2.9) |
Anxiolytics (N05B) | Diazepam, lorazepam, oxazepam | 14 (1.6) |
Drugs used in diabetes (A10) | 32 (3.7) | |
Insulins and analogues (A10A) | Insulin aspart, insulin (human, biosynthetic), insulin detemir, insulin glulisine | 32 (3.7) |
Other therapeutic groups (n = 6) | 27 (3.1) | |
Total | 872 (100.0) |
Administration routes of the identified high-alert medications
High-alert medications associated with the most serious ME reports
High-alert medication | Short description of medication errors |
---|---|
Morphine (n = 6, 33.3%) | • Infusion rate programmed 12.5 mL/h instead of 2.5 mL/h • A full daily dose prescribed six times, although the daily dose should have been divided into six doses • PO dose accidentally given IV • Three IV doses given within 30 min prior to the transfer resulted in the deterioration of the patient’s condition in the receiving unit • The patient received accidentally another patient's medicine • Morphine IV infusion prescribed and given at 3.5 mL/h instead of 0.35 mL/h |
Aspartinsulin (n = 2, 11.1%) | • CVC blood glucose samples were contaminated by glucose infusion, which led to unnecessary dose increases of IV infusion and hypoglycemia • The changes made into the insulin pump were not approved, which resulted in a new order on incorrect grounds the next day |
Enoxaparin (n = 2, 11.1%) | • A fivefold dose, because the dose was prepared from the undiluted medicine (100 mg/ml) instead of the diluted one (20 mg/ml) • The dose was decreased to from 20 to 10 mg (no prefilled syringe available), but a 100 mg syringe was mistakenly prescribed |
Oxycodone (n = 2, 11.1%) | • PO dose prescribed to IV route • A respiratory arrest resulting from a combination of too many PCA boluses and epidural analgesia |
Carboplatin (n = 1, 5.6%) | • Too rapid etoposide infusion (1 h instead of 3 h) because of a mix-up between infusion times |
Etoposide (n = 1, 5.6%) | |
Dopamine (n = 1, 5.6%) | • 100-fold infusion rate because of pump programming error (23 mL/h instead of 0.23 mL/h) |
Heparin flush (n = 1, 5.6%) | • Accidental administration of parenteral nutrition to IA line after a mix-up between infusion syringes |
Parenteral nutrition (n = 1, 5.6%) | |
Vincristine (n = 1, 5.6%) | • An extra dose given to a patient suffering from neuropathy, because the previous dose was recorded in the wrong place |
Comparison of ME severity between high-alert medications and other medications
ME severity | ME reports involving other medications n (%) | ME reports involving high-alert medications n (%) | Total n (%) | |
---|---|---|---|---|
Consequences to the patient | No harm | 707 (50.9) | 347 (46.7) | 1054 (49.4) |
Minor harm | 208 (15.0) | 135 (18.2) | 343 (16.1) | |
Moderate harm | 24 (1.7) | 27 (3.6) | 51 (2.4) | |
Severe harm | 1 (0.1) | 4 (0.5) | 5 (0.2) | |
Not known | 206 (14.8) | 110 (14.8) | 316 (14.8) | |
Not reported | 243 (17.5) | 120 (16.2) | 363 (17.0) | |
Total | 1,389 (100.0) | 743 (100.0) | 2,132 (100.0) | |
Chi-square test | X2 (5, N = 2,132) = 17,151, p = .004 | |||
Risk classification | I (insignificant risk) | 111 (8.0) | 39 (5.2) | 150 (7.0) |
II (low risk) | 851 (61.3) | 427 (57.5) | 1278 (59.9) | |
III (moderate risk) | 308 (22.2) | 237 (31.9) | 545 (25.6) | |
IV (significant risk) | 10 (0.7) | 11 (1.5) | 21 (1.0) | |
V (serious risk) | 1 (0.1) | 4 (0.5) | 5 (0.2) | |
Not reported | 108 (7.8) | 25 (3.4) | 133 (6.2) | |
Total | 1,389 (100.0) | 743 (100.0) | 2,132 (100.0) | |
Chi-square test | X2 (5, N = 2,132) = 46,669, p = .000 |