Brian J. Kopp

Medication errors and adverse drug events in an intensive care unit : Direct observation approach for detection

Objective:To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence. Design:Prospective, direct observation study. Setting:Tertiary care academic medical center. Patients:Patients in a medical/surgical intensive care unit. Interventions:Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. Measurements and Main Results:The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%). Conclusions:Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.

Clinical and Economic Analysis of Methicillin-Susceptible and -Resistant Staphylococcus aureus Infections

BACKGROUND: The rate of methicillin-resistant Staphylococcus aureus (MRSA) has increased significantly over the last decade. Previous cohort studies of patients with MRSA bacteremia have reported higher mortality rates, increased morbidity, longer hospital length of stay (LOS), and higher costs compared with patients with methicillin-susceptible S. aureus (MSSA) bacteremia. The clinical and economic impact of MRSA involving other sites of infection has not been well characterized. OBJECTIVE: To determine the clinical and economic implications of MRSA compared with MSSA infections across a variety of infection sites and severity of illnesses. METHODS: A retrospective, case—control analysis comparing differences in clinical and economic outcomes of patients with MRSA and MSSA infections was conducted at an academic medical center. Case patients with MRSA infection were matched (1:1 ratio) to control patients with MSSA infection according to age, site of infection, and type of care. RESULTS: Thirty-six matched pairs of patients with S. aureus infection were identified. Baseline characteristics of patients with MSSA and MRSA infection were similar. Patients with MRSA infections had a trend toward longer hospital LOS (15.5 vs 11 days; p = 0.05) and longer antibiotic-related LOS (10 vs 7 days; p = 0.003). Median hospital cost associated with treatment of patients with MRSA infections was higher compared with patients with MSSA infections (

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

16 575 vs

Vancomycin dosing for pneumonia in critically ill trauma patients.

12 862; p = 0.11); however, this difference was not statistically significant. Treatment failure was common in patients with MRSA infection. Among patients with MSSA infections, treatment failure was associated with vancomycin use. CONCLUSIONS: Patients with MRSA infections had worse clinical and economic outcomes compared with patients with MSSA infections.

Cost savings with interventions to reduce aerosolized bronchodilator use in mechanically ventilated patients

Objective: To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated. Design: Prospective, direct observation study. Setting: A 16-bed pediatric medical/surgical ICU at a tertiary care academic medical center. Patients: One enrolled nurse caring for at least one pediatric ICU patient age <18 yrs was randomly chosen during each observation period. Interventions: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. Measurements and Main Results: Medication errors and potential and actual ADEs were identified throughout the entire medication use process. The 26 12-hr observation periods included 357 reviewed written orders and 263 observed doses. The study observers identified 58 incidents, which were subsequently classified by the evaluators according to clinical importance, severity, and preventability. Fifty-two of these incidents were considered medication errors; six incidents were determined to be nonpreventable ADEs. Of the 52 medication errors, 42 (81%) were considered clinically important. Potential ADEs comprised 35 (83%) of these important medication errors; the other seven (17%) were classified as actual, preventable ADEs. Overall, the actual and potential ADE rate occurred at 3.6 events and 9.8 events per 100 orders, respectively. Conclusions: Our medication error rate was similar to that of previous pediatric ICU studies that used the direct observation method for reporting but higher than the rates in previous studies using other detection techniques such as voluntary incident reporting. Periodic direct observation and other ongoing data collection methods such as voluntary incident reporting have the potential to be complementary approaches to medication error and ADE detection.

Heparin dosing for venous thromboembolism prophylaxis in obese hospitalized patients: An observational study

BACKGROUND Vancomycin has been recommended as the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia with a desired trough concentration of 15 to 20 mg/L. The purpose of this study was to evaluate the initial dosing of vancomycin for MRSA pneumonia in critically ill adult trauma patients. METHODS Critically ill adult trauma patients were retrospectively identified for inclusion into the study. Patients initiated at a dose of 1 g intravenously (i.v.) every 8 hours were compared with patients initiated at a dose of 1 g i.v. every 12 hours. Baseline continuous demographic variables and steady-state vancomycin trough concentrations were compared between the two groups using a Students t test (alpha = 0.05). RESULTS There were 36 patients who satisfied criteria for inclusion, 17 patients in the 1 g every 8 hour group and 19 patients in the 1 g every 12 hour group. The mean steady-state trough concentration was higher in the 1 g every 8 hour group versus the 1 g every 12 hour group (11.1 vs. 6.8 mg/L, p = 0.014). A steady-state trough concentration greater than 15 mg/L was achieved in 23.5% of the patients in the 1 g every 8 hour group and none of the patients in the 1 g every 12 hour group. CONCLUSION A vancomycin regimen of 1 g i.v. every 12 hours in critically ill trauma patients with MRSA pneumonia and normal renal function is unlikely to achieve trough concentrations of 15 to 20 mg/L. Doses of at least 1 g i.v. every 8 hours are needed.

Perceptions of critical care pharmacists participating in a formal mentor–mentee program

PURPOSE The purpose of this evaluation is to describe the cost savings associated with multimodal interventions aimed at reducing aerosolized bronchodilator use in mechanically ventilated patients without adversely affecting costs associated with length of stay (LOS). MATERIALS AND METHODS Subjects were included in the analysis if they were aged more than 18 years, on mechanical ventilation in the intensive care unit, and received aerosolized bronchodilators. Patients were excluded if they had reversible airway disease, an indication needing bronchodilator therapy. Patient data were obtained using the University Health System Consortium Clinical Data Base/Resource Manager (Chicago, IL) to compare outcomes during two 6-month periods separated by a 4-month intervention phase aimed to reduce bronchodilator use. RESULTS There were no significant differences in age, sex, and LOS (observed and expected) between the preintervention and postintervention phases. Based on whole acquisition costs, the total cost of bronchodilators dispensed to the adult intensive care units over the 6-month postintervention phase was reduced by

Evaluation of Deprescribing Amiodarone After New-Onset Atrial Fibrillation in Critical Illness

56960 compared with the 6-month preintervention phase (

Effect of Amantadine on Agitation in Critically Ill Patients with Traumatic Brain Injury

120562 vs

Adverse drug events: are ICU patients at higher risk?

63602, respectively). CONCLUSIONS Multimodal efforts to restrict aerosolized bronchodilator therapy in mechanically ventilated patients were successful and led to sustained reductions in use that was associated with substantial reductions in cost, without affecting LOS.