Characterization of Medication Errors in a Medical Intensive Care Unit of a University Teaching Hospital in South Korea

Abstract

<b>Objectives:</b> The objective of this study was to characterize the current status of medication errors (MEs) throughout the medication therapy process from prescribing to use and monitoring for medications used in a medical intensive care unit (MICU) in Korea. <b>Methods:</b> Electronic medical records were retrospectively reviewed for adult patients hospitalized in the MICU of a university teaching hospital in Korea in 2017. The occurrence of MEs was determined based on the medication administration records. The type of MEs and the consequent ME outcome severity were categorized based on the Pharmaceutical Care Network Europe classification tool and the National Coordinating Council for Medication Error Reporting and Prevention taxonomy, respectively. <b>Results:</b> Among 78,761 medication administration records in 293 patients included in this study, 19,304 (21%) medications were administered with at least one type of ME; an estimated error incidence was 4,995 MEs per 1,000 patient-days. The majority of MEs were due to inappropriate dose (35.5%). Most of the MEs (64.8%) were harmless; however, harmful events (35.2%) occurred, including life-threatening (0.6%) and fatal (0.3%) events. Deaths occurred in two patients due to enoxaparin-induced hemorrhage and neutropenia associated with ganciclovir and cefepime. Antibiotics were common culprit medications (&gt; 15%), primarily leading to harmful events. <b>Conclusions:</b> In conclusion, MEs are prevalent in the MICU in Korea, most commonly prescribing errors. Although mostly benign, harmful events including deaths may occur due to MEs, primarily associated with antibiotics.