Self-Reporting of Medication Errors in Critically Ill Surgical Patients in the THAI-SICU Study
Thammasak Thawitsri MD*1, Kaweesak Chittawatanarat MD, PhD*2, Onuma Chaiwat MD*3, Somrat Charuluxananan MD*4, the THAI-SICU study group
Affiliation : *1 Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand *2 Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand *3 Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand *4 Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Objective : The objective of this study was to collect the data of medication errors by the self-report of doctors and nurses in
critically ill surgical patients.
Material and Method: All data were collected from THAI-SICU database in nine medical schools in Thailand during a
period of 22 months. The occurrence and medication error related factors were recorded.
Results : From 4,652 admissions, there were only 10 cases of medication error. Of these, there were only 7 cases of complete
self-report medication error, and all of them had no critical side effects. Most cases were of receiving wrong doses of medicine
especially overdosing. The medicine preparers, administrators and the error detectors were mostly nurses. For immediate
outcomes, two cases were reported of low blood pressure and one case was reported of lowering self-conscious. For long-
term outcomes, there were two cases of prolonged ICU stays. Regarding the contributing factors, the most frequent problem
found was communication. The most important factor minimizing incidents was to increase proper care. As to suggested
corrective strategies, it was found that improved supervision was most needed.
Conclusion : Reporting of medication errors by a self-report of doctors and nurses is low in this cohort, which might result
from occurrences not being reported. The wrong dose is the most common occurrence and the communication is the most
related factor.
Keywords : Critically ill patients, Medication error, SICU, Safety climate
