From The Ergoweb® Learning Center

New Study Reveals Injected Medication Errors in Intensive Care Units

Warnings about medication errors are sounded with alarming regularity. A new multinational study emphasizes the particular risks that lurk in intensive care units.  The lead researcher, Dr Andreas Valentin, warns that the administration of injected medication is a weak point in these units. The ergonomic approach to addressing the problem lies in treating the disease as well as the symptoms: The errors can be viewed as symptoms of systems with flaws that increase the risk of mistakes. 

According to the study, published in the March 2009 issue of the British Medical Journal and reported by the BBC, researchers from Rudolfstiftung Hospital collected data over a 24-hour period on more than 1,300 patients at 113 intensive care units in 27 countries. Of the 441 patients affected, seven suffered permanent harm and five died, partly because of the error.
Nearly half of the affected patients suffered more than one mistake during the period covered. The most frequent errors were related to the wrong time of administration and missing doses altogether. Cases of incorrect doses and wrong drugs being given were also reported. A total of 69 percent of the errors occurred during routine care. The odds of an error being made increased significantly for the most severely ill patients. Researchers said this reflected the complexity of their care.

The doctors and nurses who took part in the study cited stress and tiredness as a contributing factor in a third of mistakes. Recent changes in the drug’s name, poor communication between staff and violation of protocols were also mentioned. 

Fatigue makes hospital personnel particularly vulnerable to making errors.  Research published in the September 7, 2005, edition of the Journal of the American Medical Association concluded that many resident doctors are so sleep-starved they are drunk with fatigue. They reported that fatigued doctors are unproductive, inefficient and a danger to patients and themselves. 

And sleep debt also afflicts many of the nation’s 2.2 million registered nurses, 700,000 licensed practical and vocational nurses and 2.3 million nursing assistants. A study on nurses sponsored by the Agency for Healthcare Research and Quality (AHRQ), which was set up by the US Department of Health and Human Services, observes: "long work hours pose one of the most serious threats to patient safety, because fatigue slows reaction time, decreases energy, diminishes attention to detail, and otherwise contributes to errors." Nurses typically work eight- to 12-hour shifts, and some work even longer hours, according to the study.

Nurses are in prime position to prevent and intercept mistakes, but not when they are overwhelmed and tired, the AHRQ study notes.

Political and economic constraints often interfere with the first line against the fatigue issue, which is trimming over-long shifts for hospital personnel. The ergonomic assault on the problem could begin at the second line: redesigning shift patterns. Intensive care units, by necessity, are 24-hour, 7-days-a-week operations that require night shift work. Studies reported in The Ergonomics Report®, a publication for subscribers who have a professional interest in ergonomics, show that night work of any kind gambles with performance and lives because it interferes with the body’s circadian rhythm, or body clock. The clock is set for activity during the day and rest during the night. The research shows that designing shift patterns so they work with and not against this natural rhythm can make night shifts less fatiguing, impairing and stressful.
Potential solutions to issues listed as contributing factors by the doctors and nurses in the Austrian study lie in the considerable body of published ergonomics studies. For instance, ergonomics research suggests ways of redesigning medication labeling systems. Color-coding and type design have been widely investigated as tools for aiding comprehension of labels and signs. Likewise, the research points to ways systems of nomenclature, communications and protocols can be refined to reduce the risk of error. 


Andreas Valentin, et al. “Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 2009;338:b814, doi: 10.1136/bmj.b814 (Published 12 March 2009)

J. Todd Arnedt; Judith Owens; Megan Crouch; Jessica Stahl; Mary A. Carskadon
"Neurobehavioral Performance of Residents After Heavy Night Call vs After Alcohol Ingestion."
JAMA, September 7, 2005; 294: 1025 – 1033.