ORIGINAL RESEARCH Medication errors in an intensive care unit Elena Bohomol, Lais Helena Ramos & Maria D’Innocenzo Accepted for publication 21 January 2009 Correspondence to E. Bohomol: e-mail: ebohomol@uol.com.br Elena Bohomol MS PhD RN Member of the Nursing and Health Services Evaluation Studies and Research Group Sa ˜o Paulo Federal University and Professor of Nursing, Sa ˜ o Camilo University Center, Sa ˜o Paulo, Brazil Lais Helena Ramos PhD RN Professor of Nursing Sa ˜o Paulo Federal University and Vice-director of Nursing School, Sa ˜o Paulo Federal University, Sa ˜o Paulo, Brazil Maria D’Innocenzo MS PhD RN Chairwoman Nursing and Health Services Evaluation Studies and Research Group Sa ˜o Paulo Federal University and Professor of Nursing, Sa ˜o Paulo Federal University, Sa ˜o Paulo, Brazil BOHOMOL E., RAMOS L. H. BOHOMOL E., RAMOS L. H. & D’INNOCENZO M. (2009) D’INNOCENZO M. (2009) Medication errors in an intensive care unit. Journal of Advanced Nursing 65(6), 1259–1267. doi: 10.1111/j.1365-2648.2009.04979.x Abstract Title. Medication errors in an intensive care unit. Aim. This paper is a report of a study to investigating the incidence types and causes of medication errors (MEs) and the consequences for patients. Background. Medication errors are a common problem in hospitals around the world, including those in Brazil. Method. An exploratory, quantitative survey design was used and 44 adult inpatients were studied over a 30-day period in 2006. Three different methods were employed: anonymous self-reports, staff interviews and review of patient prescrip- tions. Findings. A total of 305 MEs was observed. The mean (SD SD) number was 6Æ9 (6Æ8) per patient. The numbers of MEs per day differed statistically significantly between the two groups with length of stay in the intensive care unit of <1 week and more than 1 week, respectively, with mean (SD SD) of 0Æ4 (0Æ38) vs. 0Æ73 (0Æ39) The most frequent types were: omission (71Æ1%), wrong time of administration (11Æ5%), and prescribing errors (4Æ6%). The main causes were: medication not available in the hospital (41%); pharmacy stocking and delivery problems (16Æ3%); transcription errors (11%). No death was directly related to any ME. Conclusion. There is a need to develop a culture of safety and quality in patient care. An understanding of the profile of ME types and frequencies in an institution is fundamental to raise awareness and implement measures to avoid them. Structural and procedural changes in hospital organization, with a focus on the efficacy, efficiency, and effectiveness of the medication system are needed to reduce MEs. Keywords: adults, anonymous reports, Brazil, healthcare professionals, intensive care, interviews, medication errors, record reviews Introduction Research on medication errors (MEs) and the pursuit of safer medication systems began in the 1960s in the United States of America (USA) (Flynn & Barker 1999). In 2000, the book To Err is Human: Building a Safer Health System was published. This publication is recognized as a landmark because it presented well-conducted studies involving several healthcare institutions concerning MEs and adverse events, and gave birth to profound discussions about (the lack of) safety in healthcare organizations and hospitals (Kohn et al. 2000). Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd 1259 JAN JOURNAL OF ADVANCED NURSING