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Medication Errors in Hospital Intensive Care Units Attributed to Communication Breakdowns and Improperly Programmed I.V. Pumps

Rockville, Md., February 15, 2006—The United States Pharmacopeia (USP) today announced that communication failures and improper programming of IV pumps are among the leading causes of harmful medication errors in a hospital’s Intensive Care Unit (ICU).

These causes are identified in the 6th annual MEDMARX® Data Report, which represents the largest national data set ever compiled of medication errors that occur in hospital Intensive Care Units, including coronary, general, medical and surgical ICUs.

More than four million people in the U.S. are admitted to ICUs each year, and the number of ICU admissions is expected to increase steadily, according to published reports. Medication errors are particularly significant in the ICU, since patients typically are more seriously ill, on numerous high-risk medications simultaneously, and less capable of recovering from a harmful error.

From 2000-2004, the number of reported errors that occurred in ICUs was 38,371. Nearly half of the actual medication errors originated during the prescribing (24.4%) and transcribing (24%) of the medication order. Many of the prescribing errors were associated with knowledge-related issues or communication breakdowns such as writing orders that were incomplete or incorrect, illegible handwriting, using abbreviations that were misinterpreted and a lack of familiarity with some drug information.

“The study shows that various aspects of written and verbal communications are frequently involved in medication errors, which is consistent with other patient safety research,” said John P. Santell, R.Ph., lead author of the report and director of Educational Program Initiatives for the Center for the Advancement of Patient Safety (CAPS) at USP.

“USP’s report on ICU medication errors provides additional evidence of the impact of team work and communication on medication errors and provides new knowledge regarding the importance of distractions as a cause of medication errors,” said Peter Pronovost. M.D., Ph.D., medical director, Center for Innovations in Quality Patient Care, The Johns Hopkins University School of Medicine. “Further research is needed regarding how to improve teamwork and communication and prevent distractions or minimize their impact on medication errors."

The MEDMARX Report also shows that incorrect programming of IV pumps by hospital staff resulted in a high percentage (11%) of harmful medication errors. Mix-ups in the IV tubing during pump set-up or mix-ups in programming the infusion rates for each drug have resulted in serious harm.

“IV pumps have become increasingly sophisticated electronic devices, often administering three or four completely different medications at different rates through one pump. For this reason, it is critical that all healthcare practitioners involved with drug administration be properly trained on the use of today’s IV pumps. Healthcare facilities are encouraged to review staff training and education programs for operating and trouble-shooting an IV pump,” said Santell.

The MEDMARX Data Report, A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services, analyzed 40,403 records collected from hospitals and healthcare institutions located across the country. MEDMARX is the largest nongovernmental database of medication errors in the U.S.

MEDMARX, operated by USP, is an anonymous, Internet-accessible program used by hospitals and related institutions nationwide to report, track, and analyze medication errors. Since its inception in 1998, MEDMARX has received more than one million reports of medication errors from more than 850 healthcare facilities across the U.S.

Source: United States Pharmacopeia

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