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VOLUME 27 , ISSUE 12 ( December, 2023 ) > List of Articles

Original Article

Assessment of Medication Safety Incidents Associated with High-alert Medication Use in Intensive Care Setting: A Clinical Pharmacist Approach

Priya J Aradhya, Ravina Ravi, Ballaekere Jayaram Subhash Chandra, Madhan Ramesh, Sri Harsha Chalasani

Keywords : Contributing factors, High-alert medications, Medication error, Patient safety

Citation Information : Aradhya PJ, Ravi R, Chandra BJ, Ramesh M, Chalasani SH. Assessment of Medication Safety Incidents Associated with High-alert Medication Use in Intensive Care Setting: A Clinical Pharmacist Approach. Indian J Crit Care Med 2023; 27 (12):917-922.

DOI: 10.5005/jp-journals-10071-24588

License: CC BY-NC 4.0

Published Online: 30-11-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Background: High-alert medications (HAMs) potentiate heightened risk of causing patient harm ranging from 0.24 to 89.6 errors per 100 prescriptions. High-alert medications are crucially utilized in the intensive care settings (ICUs) due to their excellent potential in delivering therapeutic efficacy, yet these medications could cause severe harm if used inappropriately. Despite the cautious use of these medications, medication safety issues persist, which compromises patient safety. Methods: A prospective interventional study was conducted in ICUs for a period of 6 months. The HAMs were adopted from the Institute for Safe Medication Practices (ISMP) list of HAMs that were used. A suitably designed medication error assessment form was used to capture the necessary data, including demographics, medications, medication error, and the contributing factors. The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) index was used to categorize the medication errors (MEs). The error rate was calculated using error rate formula. Continuous variables were expressed as mean ± standard deviation, whereas categorical variables were presented in frequencies and percentages. Results: A total of 165 patients were enrolled during the study period, with 98 (59.4%) being male and 67 (40.6%) female. The majority [54 (32.73%)] of the study participants belonged to the 61–70 age range. A total of 204 MEs were reported, of which [92 (41.5%)] errors were prescribing errors, followed by documentation errors [69 (33.82%)] and administration errors [43 (21.08%)]. The baseline medication error rate was noted to be 160.12/1,000 patient days. Potassium chloride, tramadol, propranolol, aspirin, insulin, and metoprolol were identified as the most common HAMs to cause errors. According to NCC MERP classification, 41.18% were categorized as category B, followed by category C (35.78%). An overall of 666 contributing factors (CFs) were identified for 204 errors. Stress (24.32%) was the most common factor that contributed to the MEs, followed by workload (21.47%). Conclusion: While great strides have been adopted in error prevention, yet the goal of making HAM errors “never” event has not been achieved. Thus, an active surveillance by a clinical pharmacist could support the healthcare team in promoting patient care.

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