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Open Access

Adverse medication events in the intensive care unit: avoidable or inevitable?

  • J Mitchell1,
  • F Cox1,
  • J Wagg1 and
  • J Farrimond1
Critical Care20059(Suppl 1):P261

Published: 7 March 2005


Patient SafetyNational Health ServiceMedication ErrorConsequence ClassificationNational Patient


Recent publications have focused on patient safety and managing medications effectively [1]. Adverse reactions to medicines and medication errors cost the National Health Service (NHS) approximately £0.5 billion per annum [1]. To inform practice and facilitate policy revision we explored medication errors in two specialist cardiothoracic ICUs that utilise identical reporting mechanisms.


A retrospective analysis of the DATIX risk management database was performed for the 3-year period January 2002–November 2004. These events were categorised using the National Patient Safety Agency impact and consequence classifications [2]. Events categorised as moderate or severe were individually investigated and an individual risk reduction strategy initiated.


During this 3-year period 114 medication-related adverse events were reported. There were 9.5 events per 1000 ICU bed-days. A total 14.9% of events were categorised as moderate or severe, while 85.1% were insignificant or mild.


The rate of adverse events is comparable with published work (9.5 vs 10.4) [3] but there may be significant under-reporting. However, it was considered that all major events were avoidable. The current UK Medication Safety Initiative focuses on strengthening the prescription, supply and administration of medications in the hospital setting. This study suggests that medication safety should be a priority in the ICU in 2005.

Table 1

Event type (all)

Number (% of total)

Major events (%)


20 (18)

3 (3)


11 (9)

2 (2)


18 (16)

1 (1)


23 (20)

6 (5)


32 (28)

2 (2)


4 (3)

3 (3)


7 (6)

0 (0)

Authors’ Affiliations

Royal Brompton & Harefield NHS Trust, Harefield, UK


  1. Audit Commission: A Spoonful of Sugar: Medicines Management in NHS Hospitals. Audit Commission. 2001.Google Scholar
  2. NPSA: 7 Steps to Patient Safety – Your Guide to Safer Patient Care. National Patient Safety Agency. 2004.Google Scholar
  3. Leape LL, et al.: Pharmacist participation on physician rounds and ADEs in the ICU. JAMA 1999, 282: 267-270. 10.1001/jama.282.3.267PubMedView ArticleGoogle Scholar


© BioMed Central Ltd 2005