Therapeutics and Clinical Risk Management (Apr 2019)
Interprofessional safety reporting and review of adverse events and medication errors in critical care
Abstract
Claire Chapuis,1 Sébastien Chanoine,1,2 Laurence Colombet,3 Silvia Calvino-Gunther,3 Caroline Tournegros,3 Nicolas Terzi,2–4 Pierrick Bedouch,1,2,5 Carole Schwebel2,3,6 1Pôle Pharmacie, CHU Grenoble Alpes, Grenoble 38000, France; 2Université Grenoble Alpes, Grenoble 38000, France; 3CHU Grenoble Alpes, Réanimation Médicale Pôle Urgences Médecine Aiguë, Grenoble 38000, France; 4INSERM, U1042, Université Grenoble-Alpes, HP2, Grenoble 38000, France; 5CNRS (UMR5525), TIMC-IMAG, Grenoble 38000, France; 6Inserm U1039 Radiopharmaceutiques Biocliniques, Domaine de la Merci, La Tronche 38700, France Background: The intensive care unit (ICU) environment is prone to the risk of adverse events (AEs) and medication errors (MEs). The objective of this work was to describe a multidisciplinary safety program focused on AE and ME reporting and review in an ICU over a 7-year period.Methods: The program was implemented in an 18-bed medical ICU of a 2,200-bed university hospital. A multidisciplinary steering committee (intensivist, clinical pharmacist, nurses, and research assistants) met monthly. The first part of the meeting was dedicated to the review of events targeted through an internal voluntary reporting system, and the second part concerned the analysis of the previous month’s events, according to a standardized method called Orion, inspired by the aeronautic industry.Results: A total of 808 AEs were reported, mostly related to medication processes (30.3% and 33.4% for prescription and administration, respectively). Among these, 526 AEs were related to medications (65.1%), of which 464 were MEs (88.2%). These MEs concerned mostly anti-infective drugs (23.5%) and related to wrong doses (35.8%). Among all AEs reported, 58 (43 MEs [74.1%]) were analyzed further and found to be associated with anti-infective (16.1%) and vasoactive drugs (16.1%). According to National Coordinating Council for Medication Error Reporting and Prevention classification, most AEs caused no harm to patients (category A–D: 38 events, 65.5%). Nurses were most often involved in the analysis (50.7%), along with pharmacists (37.5%). Training was identified as the most frequent corrective action (45.1%).Conclusion: This program dedicated to AE and ME reporting, review, and analysis in ICU showed long-term engagement of the health care team in AE surveillance and helped in targeting measures for education, organization, and promoting teamwork and safety. Keywords: adverse event, medication error, safety, reporting, review, interprofessional
