María Cruz Martín, coordinator of the Prevemed Project by the Semicyuc.
Los medication errors in Intensive Care Units are “something common” within the National Health System (SNS). However, as the Prevemed Report for the Prevention of medication errors in Intensive Care Unitsthe Responsibility does not only fall on health professionals but also in the resources and organization of the SNS.
As detailed in an interview with Medical Writing the coordinator of the project by the Spanish Society of Intensive, Critical Medicine and Coronary Units (Semicyuc), Maria Cruz Martin, the health professional has perception of “insecurity” that sometimes turns against them. Therefore, it calls for the implementation of technological barriers that prevent error and one protection by the health system when the professional is involved in a serious adverse event result of a medication error.
Are medication errors common?
Yes they are, medication errors are one of the main adverse events. In fact, the World Health Organization (WHO) qualifies its reduction as its third great challenge. It is one of the areas of patient safety with the greatest impact both in volume and severity.
Are they due to human error or system failure?
There are always many factors that influence the appearance of adverse effects. There is a very high percentage of human factors, but the system does not help either because there are no barriers that should prevent that human error from occurring. It is a combination of factors. Behind an adverse event there is always an unsafe action by professionals, but it is the system that should offer these barriers. Offering the safe use of the drug as in other areas does not always exist. In the end the system must try to avoid human error.
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“On many occasions it is a lapse or an oversight that occurs due to very high care loads or the high complexity of the task” |
Are human failures due to a lack of training?
There are many factors that contribute to this, lack of training would be one. On many occasions it is a lapse or an oversight that occurs due to very high care loads or the high complexity of the task. It is multifactorial. Of course, training and experience are factors that affect the person. If we talk about the critical patient, he is more vulnerable and takes many high-risk medications. There are many factors.
Do the system conditions help to make more errors?
I do not think so. What we have now is a greater culture of safety and we are more aware of the risks to which patients may be subjected. So, there is more talk about it because we are concerned about the issue. However, our system has been improving and our units are becoming more automated, that is, these barriers are being put up. Although we are still far from being perfect, that is why we have to work at all levels.
Where are we currently on the road to perfection?
We are not in a uniform situation. There are units that have come a long way in technological development and systems that reduce risks. Others have more of a safety culture and have a pharmacist on board, which is known to be a safe practice. We are missing enough. Our society made a report where the photograph of the ICUs is clearly shown and it could be said that we would be around 50 percent globally and in some areas above or below. It also then depends on each Service and Unit.
Are medication errors more prescribing or dispensing?
In principle it is in prescription and administration. What the survey shows is a perception questionnaire, but it is not something objective. In other studies we detected that the most frequent in our units are prescription and administration.
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“Incorporating a pharmacist is fundamental. This professional is a second reviewer who would avoid mistakes and also transmit pharmacological knowledge” |
Why are there more prescription errors?
For many reasons. If you review a prescription in a critical patient, it has more than 20 medications. For example, if that medication is prescribed at four and given at five, it is an error or if a dose is missing due to any error by the nurse or a shortage of drugs, it is also an error or if there is interaction with other drugs… It is a very wide range. large. Even in automated systems you can get confused when selecting the drug or it may not tell you that the patient is allergic. There are so many reasons that in the end are frequent and go beyond prescribing a drug that is not the right one.
How could these problems be solved?
There is no magic solution. As we have detected in the report, we must work in a multimodal way. We have to create a culture of safety and that the Service cares about it. We also have to train professionals and work as a team. Incorporating a pharmacist is essential. This professional is a second reviewer who would avoid mistakes and would also transmit pharmacological knowledge.
Working in an automated and systematized way is also very important. This is achieved through traceability systems and through technology, including electronic prescription. On many occasions, the preparation of drugs in the ICU is manual. There can be errors, especially at times where there are interruptions. There are systems that allow automatic preparation and that generate labels and barcodes. In the end you automate the whole process. We are working on it, but it is not yet implemented in all units.
Is this automation cost-effective?
According to the scientific literature, it is because medication errors cost a lot of money. It is not only the damage you do to the patient, but the actions to reverse it. For example, an allergy that causes cardiac arrest entails a great cost to the SNS and, in addition, can end up in lawsuits. The incorporation of these systems has a cost, but it is always efficient to work on security. This falls within the concept of digitization of the SNS and the units with the highest risk must have these systems. Surely in the long term it is cost-efficient.
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“The incorporation of automated systems has a cost, but it is always efficient to work in security” |
How much would it cost to automate an ICU?
It depends on the initial state of the ICU, there are some that are very behind and it would be more expensive. But there are others where it would be much cheaper as there is already a clinical information system. This variability must be reduced and all units must have the necessary technology. Just as you must have trained personnel to use it.
When could this disparity be resolved?
Before five years it should be solved. The new units should already be born like this and the others, although we are in a difficult moment and understanding that there are budget adjustments, their automation should be on the agenda. From the societies we are looking for projects and financing to redirect resources for it.
Does the Administration support you?
They are always generally favorable to reducing risks. However, what we have to convey is the urgency of advancing in this area, placing it on the agendas of the Administrations. There is support and we must place it as a priority.
Would it be necessary to devise a specific plan for this?
It is included in the patient safety strategy, but we should make a specific plan just like the PRAN (Antibiotic Resistance Plan) has done to specifically reduce resistance to microbes. The risks associated with medication need to be identified, which in the end is one of the most frequent processes throughout the SNS.
Are SNS reactions to adverse effects well planned?
These strategies must be very dynamic and alive. In general, they often lag behind in the face of adverse effects. The concept of security 2.0 tells us that we have to go ahead and we have to detect risks before mistakes are made, because in the end the consequences are for the patient and healthcare professionals.
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“Professionals who have been involved in a serious adverse event with important consequences are going to suffer very important psychological and emotional alterations” |
What are the consequences for healthcare professionals?
Here there is the concept of second victim. Professionals who have been involved in a serious adverse event with important consequences are going to suffer very important psychological and emotional alterations. The professional tries to do the best possible job and when there is a negative result we are blamed instead of expanding the focus to the system and seeing why there are no tools to protect it.
This generates elements of sadness and anxiety and can lead to attitudes of working with insecurity, leaving the profession or even, in the most serious cases, the suicide of the professional. The institution must have a protocol that supports it throughout the period so that the consequences are as few as possible. This requires a very high culture of safety, not punishment.
Do they feel unprotected?
There are institutions that have worked hard on it and have incorporated it into their procedure, but there is still a lot of room for improvement. There are many professionals who perceive this insecurity and see how it turns against them. The main problem is that the existing protocols are not implemented. It is necessary to train many professionals, managers and institutions, which are the third victims. They lose all their reputation with a very serious incident. The health worker must be protected so that he does not make the mistake and when he makes it. And this does not mean that we do not assume our responsibility.
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