Self-reporting of medication errors in critically ill surgical patients in the THAI-SICU study

Abstract

© 2016, Medical Association of Thailand. All rights reserved. Objective: The objective of this study was to collect the data of medication errors by the self-report of doctors and nurses in critically ill surgical patients. Material and Method: All data were collected from THAI-SICU database in nine medical schools in Thailand during a period of 22 months. The occurrence and medication error related factors were recorded. Results: From 4,652 admissions, there were only 10 cases of medication error. Of these, there were only 7 cases of complete self-report medication error, and all of them had no critical side effects. Most cases were of receiving wrong doses of medicine especially overdosing. The medicine preparers, administrators and the error detectors were mostly nurses. For immediate outcomes, two cases were reported of low blood pressure and one case was reported of lowering self-conscious. For longterm outcomes, there were two cases of prolonged ICU stays. Regarding the contributing factors, the most frequent problem found was communication. The most important factor minimizing incidents was to increase proper care. As to suggested corrective strategies, it was found that improved supervision was most needed. Conclusion: Reporting of medication errors by a self-report of doctors and nurses is low in this cohort, which might result from occurrences not being reported. The wrong dose is the most common occurrence and the communication is the most related factor.