Medication Errors in an Internal Intensive Care Unit of a Large Teaching Hospital: A Direct Observation Study

  • Afsaneh Vazin Department of Clinical Pharmacy, Faculty of Pharmacy and PharmaceuticalResearch Center, Shiraz University of Medical Sciences, Shiraz, Iran.
  • Saadat Delfani Department of Clinical Pharmacy, Faculty of Pharmacy and PharmaceuticalResearch Center, Shiraz University of Medical Sciences, Shiraz, Iran.
Medication errors, Intensive care unit, Critical care unit


Medication errors account for about 78% of serious medical errors in intensive care unit (ICU). So far no study has been performed in Iran to evaluate all type of possible medication errors in ICU. Therefore the objective of this study was to reveal the frequency, type and consequences of all type of errors in an ICU of a large teaching hospital. The prospective observational study was conducted in an 11 bed internal ICU of a university hospital in Shiraz. In each shift all processes that were performed on one selected patient was observed and recorded by a trained pharmacist. Observer would intervene only if medication error would cause substantial harm. The data was evaluated and then were entered in a form that was designed for this purpose. The study continued for 38 shifts. During this period, a total of 442 errors per 5785 opportunities for errors (7.6%) occurred. Of those, there were 9.8% administration errors, 6.8% prescribing errors, 3.3% transcription errors and, 2.3% dispensing errors. Totally 45 interventions were made, 40% of interventions result in the correction of errors. The most common causes of errors were observed to be: rule violations, slip and memory lapses and lack of drug knowledge. According to our results, the rate of errors is alarming and requires implementation of a serious solution. Since our system lacks a well-organize detection and reporting mechanism, there is no means for preventing errors in the first place. Hence, as the first step we must implement a system where errors are routinely detected and reported.


Beckmann U, Baldwin I, Hart GK, Runciman WB. The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An analysis of the first year of reporting. Anaesth Intensive Care 1996;24(3):320-9.

Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child 2000;83(6):492-7.

American Society of Health-System Pharmacist. Best Practices for Health-System Pharmacy: Positions and Guidance Documents of ASHP: American Society of Health-System Pharmacists; 2007.

Fahimi F, Abbasi Nazari M, Abrishami R, Sistanizad M, Mazidi T, Faghihi T, Soltani R, Baniasadi S. Transcription errors observed in a teaching hospital. Arch Iran Med 2009;12(2):173-5.

Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Ardakani MT. Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study. Aust Crit Care 2008;21(2):110-6.

Khalili H, Farsaei S, Rezaee H, Dashti-Khavidaki S. Role of clinical pharmacists' interventions in detection and prevention of medication errors in a medical ward. Int J Clin Pharm 2011;33(2):281-4.

Vessal G. Detection of prescription errors by a unit-based clinical pharmacist in a nephrology ward. Pharm World Sci 2010 Feb;32(1):59-65.

Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm 1991;48(12):2611-6.

Wilmer A, Louie K, Dodek P, Wong H, Ayas N. Incidence of medication errors and adverse drug events in the ICU: a systematic review. Qual Saf Health Care 2010;19(5):e7.

Capuzzo M, Nawfal I, Campi M, Valpondi V, Verri M, Alvisi R. Reporting of unintended events in an intensive care unit: comparison between staff and observer. BMC Emerg Med 2005;5(1):3.

Flaatten H, Hevrøy O. Errors in the intensive care unit (ICU). Experiences with an anonymous registration. ActaAnaesthesiol Scand 1999;43(6):614-7.

Osmon S, Harris CB, Dunagan WC, Prentice D, Fraser VJ, Kollef MH. Reporting of medical errors: an intensive care unit experience. Crit Care Med 2004;32(3):727-33.

Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet 1989;2(8659):374-6.

Simpson JH, Lynch R, Grant J, Alroomi L. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2004;89(6):F480-2.

Wilson DG, McArtney RG, Newcombe RG, McArtney RJ, Gracie J, Kirk CR, Stuart AG. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr 1998;157(9):769-74.

Calabrese AD, Erstad BL, Brandl K, Barletta JF, Kane SL, Sherman DS. Medication administration errors in adult patients in the ICU. Intensive Care Med 2001;27(10):1592-8.

Tisdale JE. Justifying a pediatric critical-care satellite pharmacy by medication-error reporting. Am J Hosp Pharm 1986;43(2):368-71.

Tissot E, Cornette C, Demoly P, Jacquet M, Barale F, Capellier G. Medication errors at the administration stage in an intensive care unit. Intensive Care Med 1999;25(4):353-9.

van den Bemt PM, Fijn R, van der Voort PH, Gossen AA, Egberts TC, Brouwers JR. Frequency and determinants of drug administration errors in the intensive care unit. Crit Care Med 2002;30(4):846-50.

Colpaert K, Claus B, Somers A, Vandewoude K, Robays H, Decruyenaere J. Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial. Crit Care 2006;10(1):R21.

Girotti MJ, Garrick C, Tierney MG, Chesnick K, Brown SJ. Medication administration errors in an adult intensive care unit. Heart Lung 1987;16(4):449-53.

Lustig A. Medication error prevention by pharmacistsan Israeli solution. Pharm World Sci 2000;22(1):21-5.

Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in

hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002;59(5):436-46.

Kiekkas P, Karga M, Lemonidou C, Aretha D, Karanikolas M. Medication errors in critically ill adults: a review of direct observation evidence. Am J Crit Care 2011;20(1):36-44.

Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med 2006;34(2):415-25.

Krähenbühl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krähenbühl S. Drug-related problems in hospitals: a review of the recent literature. Drug Saf 2007;30(5):379-407.

Shulman R, Singer M, Goldstone J, Bellingan G.Medication errors: a prospective cohort study ofhand-written and computerised physician order entryin the intensive care unit. Crit Care 2005;9(5):R516-21.

Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P, Metnitz P; Research Group on Quality Improvement of the European Society of Intensive CareMedicine (ESICM); Sentinel Events Evaluation (SEE) Study Investigators. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 2009;338:b814.

How to Cite
Vazin A, Delfani S. Medication Errors in an Internal Intensive Care Unit of a Large Teaching Hospital: A Direct Observation Study. Acta Med Iran. 50(6):425-432.