The Development and Analysis of a Database to Record Critical Incidents Associated with Intravenous Drug Administration in Critically III Patients

Staff were asked to report critical incidents associated with intravenous medications across a critical care network. These were categorised using a database by drug and drug class, seriousness and level of harm, process stage and communication factors. 139 critical incidents were identified in 3848 patient days. Noradrenaline, omeprazole, gentamicin and insulin were most commonly involved (range 6 to 9 incidents). Twenty two incidents involved drug supply, 61 prescriptions, 10 preparation and 58 administration. The use of a structured database allowed a clearer understanding of incidents to be established and we make some recommendations to improve safety. The classification database could be established across many intensive care units to improve understanding of incidents associated with intravenous medications.