Epidemiology of prescription and transcription medication errors in a cardiovascular intensive care unit

Background: Critically-ill patients admitted in Intensive Care Unit (ICU) are especially vulnerable to medication errors (ME) due to both, the pathophysiological condition and the high number of drugs required. The aims of this study were to determine the frequency and characteristics of prescription and transcription errors in a Cardiovascular ICU. Method: Prospective cohort study conducted in a Cardiovascular ICU of a Tertiary hospital. We observed the prescription and transcription stages of a non-computerized medication process during five consecutive months. The primary endpoint measure was the medication error, which was considered any type of error in the prescription or transcription of the drugs. Results: Four hundred and nine treatment sheets were observed in 163 patients. At least one ME was detected in 202 treatments (49.4%). A total of 3,130 drugs were evaluated, 305 ME (9.7%) were observed. Drugs most frequently involved in errors were: antibiotics (28%), antiulcer (17%) and analgesics (11%). The most frequent errors were: wrong duration (23.6%), route of administration (22.3%) and omission (20.3%). A total of 43% of ME reached the patients. However, only the 3.3% of them caused patient harm. Patients with medication errors had a longer ICU length of stay (P <0.01). Conclusion: In our experience, prescription and transcription errors are prevalent in the ICU treatment sheets. A quarter of them reach to patients; however, the majority have no consequences for patients