Bernhard Frey Æ Vera Buettiker Æ Maja I. Hug
Katharina Waldvogel Æ Peter Gessler Æ Daniela Ghelﬁ
Catherine Hodler Æ Oskar Baenziger
Does critical incident reporting contribute to medication
Received: 23 May 2002 / Accepted: 18 July 2002 / Published online: 18 September 2002
Ó Springer-Verlag 2002
Abstract Medication-related critical incidents (CIs)
comprise harmful and potentially harmful events. The
aim of CI monitoring is quality improvement through
system changes. In a prospective survey, we analysed our
drug-related CIs of the year 2001 with an emphasis on
how they contributed to system changes. A voluntary,
anonymous, non-punitive CI reporting was used. The
study was performed in a multidisciplinary, 23-bed,
neonatal-paediatric intensive care unit (ICU). CI sever-
ity was graded: minor (no interventions required),
moderate (requiring routine therapy, available outside
the ICU), major (need for therapeutic interventions
speciﬁc to the ICU). There were 284 drug-related CIs,
76% (95% conﬁdence interval 71%–81%) of minor,
19% of moderate and 5% of major severity. A total of
24 CIs were potentially life threatening (if not detected).
Some 27% of CIs were intercepted, 17% before prepa-
ration and 10% before administration of the drug to the
patient. There was a negative correlation between
median delay (from CI to detection) and mean severity
of the diﬀerent drug classes involved (P=0.027). As to
the impact on quality, 46 CIs were followed by system
changes and 63% (95% conﬁdence interval 49%–77%)
of these CIs were of minor severity. Examples of system
changes are: double checking for potentially harmful
drugs, standardised prescription form and contact to the
national drug control agency regarding misleading drug
labels. Conclusion: most of the system changes were
based on minor critical incidents which were often
detected only after a longer period of time. This shows
the value of our ‘‘low-threshold’’ critical incident mon-
itoring. Repeated checks along the drug delivery process
(prescription, preparation, administration) are an
important means to reduce adverse drug events.
Keywords Adverse drug events Æ Critical incidents Æ
Intensive care Æ Quality improvement
Abbreviations CI critical incident Æ ICU intensive care
Critical incident (CI) monitoring is increasingly used in
medicine as a tool to improve quality of care. CIs
comprise harmful and potentially harmful events.
Knowledge of their occurrence is regarded as an im-
portant source of information for quality improvement
through system changes. This system approach recog-
nises errors as evidence of deﬁciencies in systems, not
deﬁciencies in people .
There are several studies on CI monitoring in adult
and paediatric intensive care [1, 2, 4, 7, 11, 18, 22, 23].
All these studies show alarmingly high numbers of CIs.
However, these reports focus only on the ﬁrst two steps
of CI monitoring, that is collection and analysis of CIs.
Information is scarce about the third step, namely the
implementation of system changes and about how CI
reporting contributes to these changes.
In neonatal and paediatric intensive care, drug errors
are an important source of iatrogenic morbidity [3, 9, 12,
18, 20, 21, 22]. We have previously shown that the number
of drug incidents ranked ﬁrst in a survey on voluntary CI
reporting . The present study focuses on drug-related
CIs and aims at analysing the association between CI
reporting and system changes, that is the impact of our
CI monitoring on drug safety improvement.
The study was performed in a multidisciplinary, 23-bed, neona-
tal-paediatric intensive care unit (ICU) of a university teaching
Eur J Pediatr (2002) 161: 594–599
B. Frey (&) Æ V. Buettiker Æ M.I. Hug Æ K. Waldvogel Æ P. Gessler
D. Ghelﬁ Æ C. Hodler Æ O. Baenziger
Department of Intensive Care and Neonatology,
University Children’s Hospital, Steinwiesstrasse 75,