Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level

Background: Fluid therapy is a common intervention in critically ill patients. Fluid therapy errors may cause harm to patients. Thus, understanding of reported fluid therapy incidents is required in order to learn from them and develop protective measures, including utilizing expertise of pharmacist...

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Autores principales:	Minna Kurttila, Susanna Saano, Raisa Laaksonen
Formato:	article
Lenguaje:	EN
Publicado:	Elsevier 2021
Materias:	Fluid therapy Incident reporting Intensive care ICU Patient safety Medication error Pharmacy and materia medica RS1-441
Acceso en línea:	https://doaj.org/article/6a3f365052234192af5fe9d9350afab4
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spelling	oai:doaj.org-article:6a3f365052234192af5fe9d9350afab42021-11-04T04:44:35ZDescribing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level2667-276610.1016/j.rcsop.2021.100012https://doaj.org/article/6a3f365052234192af5fe9d9350afab42021-06-01T00:00:00Zhttp://www.sciencedirect.com/science/article/pii/S2667276621000123https://doaj.org/toc/2667-2766Background: Fluid therapy is a common intervention in critically ill patients. Fluid therapy errors may cause harm to patients. Thus, understanding of reported fluid therapy incidents is required in order to learn from them and develop protective measures, including utilizing expertise of pharmacists and technology to improve patient safety at the national level. Objectives: To describe fluid therapy incidents voluntarily reported in intensive care and high dependency units (ICUs) to a national incident reporting system, by investigating the error types, fluid products, consequences to patients and actions taken to alleviate them, and to identify at which phase of the medication process the incidents had occurred and had been detected. Methods: Medication related voluntarily reported incident (n = 7623) reports were obtained from all ICUs in 2007–2017. Incidents concerning fluid therapy (n = 2201) were selected. The retrospective analysis utilized categorized data and narrative descriptions of the incidents. The results were expressed as frequencies and percentages. Results: Most voluntarily reported incidents had occurred during the dispensing/preparing phase (n = 1306, 59%) of the medication process: a point of risk. Most incidents (n = 1975, 90%) had reached the patient and passed through many phases in the medication process and nursing shift change checks before detection. One third of the errors (n = 596, 30%) were reported to have caused consequences to patients. One quarter (n = 492, 25%) of the errors were reported to have required an additional procedure to alleviate or monitor the consequences. Conclusions: Utilizing national incident report data enabled identifying systemic points of risk in the medication process and learning to improve patient safety. To prevent similar incidents, initial interventions should focus on the dispensing/preparing phase before implementing active medication identification procedures at each phase of the medication process and nursing shift changes. Strengthening clinical pharmacy services, utilizing technology, coordinated by IV Fluid Coordinators and Medication Safety Officers, could improve patient safety in the ICUs.Minna KurttilaSusanna SaanoRaisa LaaksonenElsevierarticleFluid therapyIncident reportingIntensive careICUPatient safetyMedication errorPharmacy and materia medicaRS1-441ENExploratory Research in Clinical and Social Pharmacy, Vol 2, Iss , Pp 100012- (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	Fluid therapy Incident reporting Intensive care ICU Patient safety Medication error Pharmacy and materia medica RS1-441
spellingShingle	Fluid therapy Incident reporting Intensive care ICU Patient safety Medication error Pharmacy and materia medica RS1-441 Minna Kurttila Susanna Saano Raisa Laaksonen Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level
description	Background: Fluid therapy is a common intervention in critically ill patients. Fluid therapy errors may cause harm to patients. Thus, understanding of reported fluid therapy incidents is required in order to learn from them and develop protective measures, including utilizing expertise of pharmacists and technology to improve patient safety at the national level. Objectives: To describe fluid therapy incidents voluntarily reported in intensive care and high dependency units (ICUs) to a national incident reporting system, by investigating the error types, fluid products, consequences to patients and actions taken to alleviate them, and to identify at which phase of the medication process the incidents had occurred and had been detected. Methods: Medication related voluntarily reported incident (n = 7623) reports were obtained from all ICUs in 2007–2017. Incidents concerning fluid therapy (n = 2201) were selected. The retrospective analysis utilized categorized data and narrative descriptions of the incidents. The results were expressed as frequencies and percentages. Results: Most voluntarily reported incidents had occurred during the dispensing/preparing phase (n = 1306, 59%) of the medication process: a point of risk. Most incidents (n = 1975, 90%) had reached the patient and passed through many phases in the medication process and nursing shift change checks before detection. One third of the errors (n = 596, 30%) were reported to have caused consequences to patients. One quarter (n = 492, 25%) of the errors were reported to have required an additional procedure to alleviate or monitor the consequences. Conclusions: Utilizing national incident report data enabled identifying systemic points of risk in the medication process and learning to improve patient safety. To prevent similar incidents, initial interventions should focus on the dispensing/preparing phase before implementing active medication identification procedures at each phase of the medication process and nursing shift changes. Strengthening clinical pharmacy services, utilizing technology, coordinated by IV Fluid Coordinators and Medication Safety Officers, could improve patient safety in the ICUs.
format	article
author	Minna Kurttila Susanna Saano Raisa Laaksonen
author_facet	Minna Kurttila Susanna Saano Raisa Laaksonen
author_sort	Minna Kurttila
title	Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level
title_short	Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level
title_full	Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level
title_fullStr	Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level
title_full_unstemmed	Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level
title_sort	describing voluntarily reported fluid therapy incidents in the care of critically ill patients: identifying, and learning from, points of risk at the national level
publisher	Elsevier
publishDate	2021
url	https://doaj.org/article/6a3f365052234192af5fe9d9350afab4
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Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level

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