Nursing implications for prevention of adverse drug events in the intensive care unit Elisabeth L. George, RN, PhD; Elizabeth A. Henneman, RN, PhD, CCNS, FAAN; Frederick J. Tasota, RN, MSN A dverse drug events (ADEs) are harmful and occur with alarm- ing frequency in critically ill pa- tients (1–3). The high rate of ADEs is particularly disconcerting with the current shortage of nurses, who are pri- marily responsible for the administration and monitoring of medication therapy in hospitalized patients. Patients in intensive care units (ICUs) are at particularly high risk for ADEs as a result of their medical conditions, complex care, and the hectic pace of the environment (4, 5). The recognition of patients at risk for ADEs is essential if nurses are to appro- priately prioritize their interventions and evaluation activities. Time constraints and a lack of technological support leave the busy ICU nurse with little opportu- nity to adequately monitor risk factors. Nurses must “know” their patients to provide optimal care (6, 7). In addition, mechanisms for detecting patient and treatment characteristics that may alert nurses to at-risk situations have the potential to reduce ADEs and improve patient outcomes (8). An important goal for healthcare professionals is to establish structures and processes that assist in identifying patients at risk for ADEs and uncover- ing errors when they occur. These structures and processes must be devel- oped by nursing staff, administrative nurses, and other stakeholders to as- sure that they are both evidence-based and practical in the work environment. Because medication management is a multidisciplinary process, it is important that all members of the ICU team (includ- ing patients and families) be involved in process improvement activities. Hospital administrators have a re- sponsibility to ensure that systems and policies are in place to support the bed- side nurse’s role in performing safe pro- cesses. These include management of high-alert medications, procedures in- corporating safe hand-offs with transfers and shift-to-shift reports, availability of unit-based pharmacists, and accessibility to medication information. In addition, administrators are responsible for creat- ing cultures in which staff input regard- ing safety issues is not only welcomed but also rewarded (no blame/no shame) (5). Case study Nurses A and B are working in a 10- bed ICU. Each nurse has a two-patient assignment. Nurse A’s assignment re- quires her to transport one of her pa- tients emergently to a computerized to- mography scan. Nurse A asks nurse B to cover for her while she is off the unit. Nurse B (nurse covering) performs rou- tine vital signs on the patient and, with best intentions, decides to administer the scheduled 1400 medications, one of which is 10 mEq potassium in 100 mL of dextrose to be administered intrave- nously (IV) over 1 hr. Nurse B accesses the medication dispenser to obtain the potassium, but there is none in the pa- tient’s drawer. To expedite administra- tion, she “borrows” a prefilled potassium bag from another patient’s drawer and proceeds to administer the medication. Unfortunately, the medication she “bor- rows” and administers contains 20 mEq potassium. Later in the shift, nurse A returns to the unit and resumes care of both of her patients. She asks nurse B if she has ad- ministered the potassium infusions. Dur- ing the course of the discussion, nurse A reveals she had earlier received a verbal From University of Pittsburgh Medical Center Pres- byterian (ELG), University of Pittsburgh School of Nurs- ing, Pittsburgh, Pennsylvania; School of Nursing (EAH), University of Massachusetts, Amherst, Massachusetts; University of Pittsburgh Medical Center Presbyterian (FJT), Pittsburgh, Pennsylvania. The authors have not disclosed any potential con- flict of interest. For information regarding this article, E-mail: Bethann953@aol.com Copyright © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3181de0b23 Adverse drug events are common in the intensive care unit setting. Despite the existence of many long-standing safety prin- ciples (such as the “five rights”) and new mechanisms to promote medication safety, there is still a gap between practice and the goal of patient safety. This is the result of the many human and system factors that impact care delivery. Research supports the role of the nurse as having a positive impact on patient outcomes. Future research requires the evaluation of new strategies and technologies to support safe medication administration. For ex- ample, patient simulation is being used to teach student and novice nurses principles of medication administration in a “safe” setting that more closely resembles the clinical environment. The Institute of Nursing repeatedly has stressed the need to address the organizational, technical, and human issues that impact pa- tient safety, with an emphasis on the need to transform the nurse work environment to keep patients safe. This transformation will require a new level of interdisciplinary research and nursing involvement to address better care for our patients and, in par- ticular, reduce adverse drug events. (Crit Care Med 2010; 38[Suppl.]:S136 –S144) KEY WORDS: nursing; adverse drug events; medical error; med- ication error; patient safety; nurse-sensitive outcomes; Eindhoven model; nurse recovery of error; critically ill patient S136 Crit Care Med 2010 Vol. 38, No. 6 (Suppl.)