Use of an anonymous medication incident reporting system on a critical care unit

Introduction

An anonymous error reporting system was trialled to establish whether error reporting rates would improve and to allow the identification of medication incidents. The National Patient Safety Agency (NPSA) feedback report for the Norfolk and Norwich Hospital shows that, compared with similar organisations, medication error reporting is low. A review of the medication incidents reported for the critical care facility in 2007 and 2008 had only 19 events. Error rates in the ICU are typically higher than in other acute settings, one study reporting 10.5 medication errors per 100 bed-days [1]. Patients in critical care typically receive high-risk medications. Error reporting is integral to identifying common errors and medication risk reduction.

Methods

A medication reporting form was developed to run alongside the official hospital incident reporting system for 2 weeks. Forms were distributed throughout the critical care facility. All members of the multidisciplinary team were asked to anonymously complete a form every time a medication error, or near miss, occurred. After 2 weeks, the submitted forms were analysed by the project team.

Results

In total 112 reports were submitted. The largest numbers of incidents reported were due to prescribing (67%) errors followed by administration (15%), documentation (7%), electronic prescribing problems (6%), storage (3%) and monitoring (2%). Within prescribing incidents there were four recurring themes: duplication of therapy, wrong/inappropriate drug choice, incorrect dose/regimen and omission. The numbers of incidents reported increased as the week progressed, with the largest number occurring on a Friday (24%). A review of the types of medicines involved showed that insulins, proton pump inhibitors, anticoagulants, vancomycin, and epidurals were recurring themes, reflecting NPSA alerts. When graded for significance, two were found to be harmful, 56 significant and 54 insignificant.

Conclusions

There is clearly considerable under-reporting of medication errors in critical care via the official incident reporting system. One of many reasons for poor official reporting of errors is the lack of tangible local response to those errors. It is therefore important that the areas highlighted by our project are effectively addressed, not only to improve safety but also to encourage further reporting and work to develop a culture of incident reporting within critical care.