title: Does critical incident reporting contribute to medication error prevention?
abstract: Medication-related critical incidents (CIs) comprise harmful and potentially harmful events. The aim of CI monitoring is quality improvement through system changes. In a prospective survey, we analysed our drug-related CIs of the year 2001 with an emphasis on how they contributed to system changes. A voluntary, anonymous, non-punitive CI reporting was used. The study was performed in a multidisciplinary, 23-bed, neonatal-paediatric intensive care unit (ICU). CI severity was graded: minor (no interventions required), moderate (requiring routine therapy, available outside the ICU), major (need for therapeutic interventions specific to the ICU). There were 284 drug-related CIs, 76% (95% confidence interval 71%-81%) of minor, 19% of moderate and 5% of major severity. A total of 24 CIs were potentially life threatening (if not detected). Some 27% of CIs were intercepted, 17% before preparation and 10% before administration of the drug to the patient. There was a negative correlation between median delay (from CI to detection) and mean severity of the different drug classes involved (P = 0.027). As to the impact on quality, 46 CIs were followed by system changes and 63% (95% confidence interval 49%-77%) of these CIs were of minor severity. Examples of system changes are: double checking for potentially harmful drugs, standardised prescription form and contact to the national drug control agency regarding misleading drug labels.
  
  
  CONCLUSIONS
  most of the system changes were based on minor critical incidents which were often detected only after a longer period of time. This shows the value of our "low-threshold" critical incident monitoring. Repeated checks along the drug delivery process (prescription, preparation, administration) are an important means to reduce adverse drug events.
authors.affiliation: Department of Intensive Care and Neonatology, University Children's Hospital, Steinwiesstrasse 75, 8032 Zürich, Switzerland. Bernhard.Frey@kispi.unizh.ch
authors.forename: Bernhard
authors.initials: B
authors.lastname: Frey
authors.forename: Vera
authors.initials: V
authors.lastname: Buettiker
authors.forename: Maja I
authors.initials: MI
authors.lastname: Hug
authors.forename: Katharina
authors.initials: K
authors.lastname: Waldvogel
authors.forename: Peter
authors.initials: P
authors.lastname: Gessler
authors.forename: Daniela
authors.initials: D
authors.lastname: Ghelfi
authors.forename: Catherine
authors.initials: C
authors.lastname: Hodler
authors.forename: Oskar
authors.initials: O
authors.lastname: Baenziger
mesh_terms: D002648:Child; D030881:Disclosure; D016903:Drug Monitoring; D004349:Drug Packaging; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000458:organization & administration / Q000592:standards*; D015278:Intensive Care Units, Pediatric / Q000458:organization & administration / Q000592:standards*; D008508:Medication Errors / Q000517:prevention & control*; D011785:Quality Assurance, Health Care / Q000379:methods*; D012308:Risk Management; D013557:Switzerland