Medication Error Propagation In Intensive Care Units

Abstract

We examined propagation of medication errors at various stages of the medication management process (ordering, transcription, preparation, dispensing, administration and monitoring) in two ICUs of a medical center. We performed a secondary analysis of 1,732 medication events identified in a group of 630 ICU patients. A Markov Chain model showed that errors propagate throughout the medication management process, in particular between the stages of preparation, dispensing and administration.