PMID- 31037029
OWN - NLM
STAT- PubMed-not-MEDLINE
LR  - 20220408
IS  - 1176-6336 (Print)
IS  - 1178-203X (Electronic)
IS  - 1176-6336 (Linking)
VI  - 15
DP  - 2019
TI  - Interprofessional safety reporting and review of adverse events and medication 
      errors in critical care.
PG  - 549-556
LID - 10.2147/TCRM.S188185 [doi]
AB  - BACKGROUND: The intensive care unit (ICU) environment is prone to the risk of 
      adverse events (AEs) and medication errors (MEs). The objective of this work was 
      to describe a multidisciplinary safety program focused on AE and ME reporting and 
      review in an ICU over a 7-year period. METHODS: The program was implemented in an 
      18-bed medical ICU of a 2,200-bed university hospital. A multidisciplinary 
      steering committee (intensivist, clinical pharmacist, nurses, and research 
      assistants) met monthly. The first part of the meeting was dedicated to the 
      review of events targeted through an internal voluntary reporting system, and the 
      second part concerned the analysis of the previous month's events, according to a 
      standardized method called Orion, inspired by the aeronautic industry. RESULTS: A 
      total of 808 AEs were reported, mostly related to medication processes (30.3% and 
      33.4% for prescription and administration, respectively). Among these, 526 AEs 
      were related to medications (65.1%), of which 464 were MEs (88.2%). These MEs 
      concerned mostly anti-infective drugs (23.5%) and related to wrong doses (35.8%). 
      Among all AEs reported, 58 (43 MEs [74.1%]) were analyzed further and found to be 
      associated with anti-infective (16.1%) and vasoactive drugs (16.1%). According to 
      National Coordinating Council for Medication Error Reporting and Prevention 
      classification, most AEs caused no harm to patients (category A-D: 38 events, 
      65.5%). Nurses were most often involved in the analysis (50.7%), along with 
      pharmacists (37.5%). Training was identified as the most frequent corrective 
      action (45.1%). CONCLUSION: This program dedicated to AE and ME reporting, 
      review, and analysis in ICU showed long-term engagement of the health care team 
      in AE surveillance and helped in targeting measures for education, organization, 
      and promoting teamwork and safety.
FAU - Chapuis, Claire
AU  - Chapuis C
AD  - Pole Pharmacie, CHU Grenoble Alpes, Grenoble 38000, France, 
      cchapuis1@chu-grenoble.fr.
FAU - Chanoine, Sebastien
AU  - Chanoine S
AD  - Pole Pharmacie, CHU Grenoble Alpes, Grenoble 38000, France, 
      cchapuis1@chu-grenoble.fr.
AD  - Universite Grenoble Alpes, Grenoble 38000, France.
FAU - Colombet, Laurence
AU  - Colombet L
AD  - CHU Grenoble Alpes, Reanimation Medicale Pole Urgences Medecine Aigue, Grenoble 
      38000, France.
FAU - Calvino-Gunther, Silvia
AU  - Calvino-Gunther S
AD  - CHU Grenoble Alpes, Reanimation Medicale Pole Urgences Medecine Aigue, Grenoble 
      38000, France.
FAU - Tournegros, Caroline
AU  - Tournegros C
AD  - CHU Grenoble Alpes, Reanimation Medicale Pole Urgences Medecine Aigue, Grenoble 
      38000, France.
FAU - Terzi, Nicolas
AU  - Terzi N
AD  - Universite Grenoble Alpes, Grenoble 38000, France.
AD  - CHU Grenoble Alpes, Reanimation Medicale Pole Urgences Medecine Aigue, Grenoble 
      38000, France.
AD  - INSERM, U1042, Universite Grenoble-Alpes, HP2, Grenoble 38000, France.
FAU - Bedouch, Pierrick
AU  - Bedouch P
AD  - Pole Pharmacie, CHU Grenoble Alpes, Grenoble 38000, France, 
      cchapuis1@chu-grenoble.fr.
AD  - Universite Grenoble Alpes, Grenoble 38000, France.
AD  - CNRS (UMR5525), TIMC-IMAG, Grenoble 38000, France.
FAU - Schwebel, Carole
AU  - Schwebel C
AD  - Universite Grenoble Alpes, Grenoble 38000, France.
AD  - CHU Grenoble Alpes, Reanimation Medicale Pole Urgences Medecine Aigue, Grenoble 
      38000, France.
AD  - Inserm U1039 Radiopharmaceutiques Biocliniques, Domaine de la Merci, La Tronche 
      38700, France.
LA  - eng
PT  - Journal Article
DEP - 20190402
PL  - New Zealand
TA  - Ther Clin Risk Manag
JT  - Therapeutics and clinical risk management
JID - 101253281
PMC - PMC6450184
OTO - NOTNLM
OT  - adverse event
OT  - interprofessional
OT  - medication error
OT  - reporting
OT  - review
OT  - safety
COIS- Disclosure SC reports personal fees from AstraZeneca and nonfinancial support 
      from Boehringer Ingelheim, Actelion Pharmaceuticals, and MSD outside the 
      submitted work. NT reports personal fees from Lilly Oncology, Boehringer 
      Ingelheim, and Pfizer outside the submitted work. The other authors report no 
      conflicts of interest in this work.
EDAT- 2019/05/01 06:00
MHDA- 2019/05/01 06:01
PMCR- 2019/04/02
CRDT- 2019/05/01 06:00
PHST- 2019/05/01 06:00 [entrez]
PHST- 2019/05/01 06:00 [pubmed]
PHST- 2019/05/01 06:01 [medline]
PHST- 2019/04/02 00:00 [pmc-release]
AID - tcrm-15-549 [pii]
AID - 10.2147/TCRM.S188185 [doi]
PST - epublish
SO  - Ther Clin Risk Manag. 2019 Apr 2;15:549-556. doi: 10.2147/TCRM.S188185. 
      eCollection 2019.