“You have to protect the toilet.”

Maria Cruz Martin, Prevemed Project Coordinator by Semicyuc.

The medication errors In intensive care units a “common thing” within the National Health System (SNS). However, as the Prevemed report showed to prevent medication errors in intensive care units, The responsibility lies not only with health professionals But also in the resources and organization of SNS.

As detailed in an interview with medical writing Project Coordinator by the Spanish Society of Intensive and Critical Medicine and Coronary Units (Semicyuc), Maria Cruz Martin His health specialist Visualize the “insecurity” that sometimes turns on them. Therefore, it calls for the implementation of Technological barriers that prevent error and one protection By the health system when the professional You participate in a serious adverse event As a result of a medication error.

Are medication errors common?

Yes it is, medication errors are one of the major adverse events. In fact, the World Health Organization (WHO) considers curtailing its third biggest challenge. It is one of the areas of patient safety with the greatest impact in terms of size and severity.

Is it due to human error or system failure?

There are always many factors that influence the appearance of adverse effects. There is a very high proportion of human factors, but the system also does not help because there are no barriers that should prevent this human error from happening. It is a combination of factors. Behind any adverse event, there is always an unsafe procedure by professionals, but it is the system that must provide these barriers. There is not always a presentation of the safe use of the drug as in other areas. Ultimately the system must try to avoid human error.


“Often an error or error occurs due to too high burdens of care or too much complexity of the task”



Is human failure the result of a lack of training?

There are many factors that contribute to this, lack of training will be one of them. Oftentimes this is a mistake or an omission that occurs due to very high burdens of care or a significant complexity of the task. It is multifactorial. Of course, training and experience are factors that affect a person. If we talk about the critical patient, then he is more at risk and takes many high-risk medications. There are many factors.

Do system conditions help you make more mistakes?

I don’t believe in that. What we have now is a greater safety culture and we are more aware of the risks that patients may be exposed to. Therefore, there is more talk about it because we are concerned about this issue. However, our system is improving and our units are becoming more automated, i.e. these barriers are being put in place. Although we are still far from perfect, that is why we have to work at all levels.

Where are we currently on the path to perfection?

We are not in a uniform situation. There are units that have come a long way in technological development and systems that reduce risks. Others have a safety culture and have a pharmacist on board, which is known to be a safe practice. We miss enough. Our community made a report where the ICU picture is clearly displayed and it can be said that we will be about 50 percent globally and in some regions higher or lower. Then it also depends on each service and unit.

Are medication errors more in prescribing or dispensing medications?

In principle it is in the recipe and administration. What the survey showed is a perception questionnaire, but it is not an objective thing. In other studies we have found that the most common medications in our units are prescription and abuse.


“Incorporating a pharmacist is key. This professional is the second reviewer who will avoid mistakes and also impart pharmaceutical knowledge”



Why are there more prescription errors?

For several reasons. If you review a critical patient’s prescription, you’ll find more than 20 medications. For example, if this drug is prescribed at four o’clock and given at five, then this is wrong, or if the dose is missing due to any error by the nurse or lack of medicines, then this is also wrong, or if there is an interaction with other drugs … It is a very broad scope. big. Even in automated systems, you may feel confused when choosing a drug or it may not tell you that the patient has an allergy. There are many reasons that eventually recur and go beyond prescribing an incorrect drug.

How can these problems be solved?

There is no magic solution. As we found out in the report, we have to work in a multimodal way. We have to create a culture of safety and that service cares about it. We also have to train professionals and work as a team. It is necessary to incorporate a pharmacist. This professional is the second reviewer who avoids mistakes and also imparts pharmacological knowledge.

Working in an automated and methodical manner is also important. This is achieved through tracking systems and through technology, including electronic prescriptions. Often the preparation of medicines in the intensive care unit is manual. There can be errors, especially at times when there are outages. There are systems that allow for automatic preparation and create labels and barcodes. In the end you automate the whole process. We are working on it, but it is not yet implemented in all modules.

Is this automation cost effective?

According to the scientific literature, the reason for this is that medication errors cost a lot of money. It’s not just the harm it does to the patient, but the actions to reverse it. For example, allergies that cause cardiac arrest incur a significant cost to SNS, plus they can end in lawsuits. Integrating these systems has a cost, but it is always effective to work out security. This falls within the concept of SNS digitization and the higher risk units must own these systems. Certainly in the long run it is cost-effective.


“Integrating automated systems has a cost, but it is always cost-effective to work in the field of security”



What is the cost of ICU automation?

It depends on the initial condition of the ICU, there are some that are very late and will be more expensive. But there are other countries that may be much cheaper where there is already a clinical information system in place. This discrepancy must be reduced and all units must have the necessary technology. Just as you must have trained personnel to use it.

When can this disparity be resolved?

Five years ago should be resolved. New units should already be born like this and other units, although we are going through a difficult moment and understand that there are budget adjustments, automation of which should be on the agenda. We are looking for projects and funding from the communities to redirect resources to them.

Does the administration support you?

They are always generally favorable for risk reduction. However, what we have to convey is the urgent need to advance in this area, and put it on departmental agendas. There is support and we must make it a priority.

Is it necessary to develop a specific plan for this?

It is included in the patient safety strategy, but we must develop a specific plan just like the PRAN (plan for antibiotic resistance) to specifically reduce antimicrobial resistance. The risks associated with medication, which is ultimately one of the most common operations throughout the SNS, must be identified.

Are SNS reactions to adverse effects well planned?

These strategies must be very dynamic and dynamic. In general, they often lag behind in the face of adverse effects. Security 2.0 tells us that we have to move forward and we have to discover risks before we make mistakes, because ultimately the consequences will be for the patient and healthcare professionals.


“Professionals who have been involved in a serious adverse event with catastrophic consequences will suffer very significant psychological and emotional changes.”



What are the consequences for healthcare professionals?

Here there is the concept of the second victim. Professionals who have been involved in a serious adverse event with significant consequences will suffer very significant psychological and emotional changes. The professional tries to do the best job possible and when there is a negative outcome it is blamed on us rather than broadening the focus on the system and figuring out why there are no tools to protect it.

This generates elements of sadness and anxiety and can lead to situations of working with insecurities, leaving the profession or even in the most serious cases, the suicide of a professional. The organization should have a protocol that supports it throughout the period so that the consequences are as few as possible. This requires a very high culture of safety, not punishment.

Do they feel unprotected?

There are organizations that have worked hard on this and incorporated it into their procedures, but there is still much room for improvement. There are many professionals who are aware of this feeling of insecurity and see how it turns against them. The main problem is that existing protocols are not implemented. It is necessary to train many professionals, managers and institutions, who are the third victims. They have lost all their reputation due to a very serious accident. The health worker must be protected so that he does not make the mistake and when he does it. This does not mean that we are not responsible.

Although it may contain statements, statements, or notes from health institutions or professionals, the information in medical writing is edited and prepared by journalists. We recommend the reader to consult a health professional for any health-related questions.

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