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5PSQ-049 Medication prescribing errors prospective observational study in an Intensive Care Unit
  1. A Pérez Plasencia1,
  2. M Vila Currius1,
  3. P Ortiz Ballujera2,
  4. A Dorda Benito1,
  5. E Nogue Pujadas1,
  6. N Samper Sanchez2,
  7. M Bruguera Teixidor1,
  8. C Subirana Batlle1,
  9. N Vilanova Anducas3,
  10. R Aguilar Salmerón1
  1. 1Hospital Universitari Dr. Josep Trueta, Pharmacy Department, Girona, Spain
  2. 2Hospital Universitari Dr. Josep Trueta, Intensive Care Unit, Girona, Spain
  3. 3Hospital Universitari Dr. Josep Trueta, Internal Medicine Department, Girona, Spain


Background and Importance Prescribing errors (PE) are an important cause of medication-related adverse events in Intensive Care Units (ICU) but limited data are available in ICU with electronic prescribing and administration (ePA) systems.

Aim and Objectives To determine the rate of PE in an ICU with ePA system, to classify incident types and to identify critical points where measures should be implemented to improve patient safety.

Material and Methods Prospective, observational and cross-sectional study in an ICU with ePA system during five working days (november 2021). The inclusion criteria were ICU inpatients with an electronic prescription. Prescriptions were recollected and analysed by a multidisciplinary team comprised of a pharmacist, an ICU physician, a nurse and the person in charge of the hospital’s Medication Errors Committee. PE were reported to the hospital’s patient safety-related incident notification system.

Results 30 patient prescriptions, with 441 medications prescribed, were revised during the study period. The patients’ average age was 60.7 ± (SD=13.2) years and each prescription had an average of 14.7 medications. PE were reported in 31 cases and two situations with the capacity to cause errors were detected. The rate of PE was 1.03 errors per patient, 0.07 per prescribed medication and 53% of patient prescriptions were PE free. The most common types of PE were wrong dose (33.3%), excessive duration (29.0%), drug not indicated by clinical situation (12.9%) and no administration prescribed medication (12.9%). Results were communicated to staff physicians and residents with recommendations to minimise them: enteral nutrition adjustment if a propofol treatment initiated or modified, use available protocols in ePA system, review and eliminate non-active treatments and be especially careful with care transitions.

Conclusion and Relevance This study has made it possible to identify the weak points of medication prescription in our ICU. The realisation of periodic PE studies allows us to establish the impact of the implemented actions and to define new objectives to improve patient safety.

Conflict of Interest No conflict of interest.

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