Reactions 1216 - 23 Aug 2008 Room for improvement in medication-associated safety incidents Drug administration was associated with over half of the medication incidents in critical care, according to a review of reports submitted to the UK National Safety Agency; the drugs most commonly associated with patient harm were morphine, norepinephrine [noradrenaline] and gentamicin. The researchers reviewed and classified patient incidents occurring in ICU or high dependency units that were submitted to the Agency between August 2006 and February 2007; the incidents involving medications were then categorised. 2428 incidents associated with medication use involving 355 different drugs were submitted. The drugs that were associated with more than 1% of all the 2428 incidents were morphine followed by gentamicin then insulin. The drugs that were most commonly associated with patient harm included insulin (48 incidents), morphine (22), and norepinephrine (55). Drug administration was the most common cause of incidents associated with norepinephrine. Drug administration was associated with 61% of medication incidents, and caused the largest number of incidents involving patient harm. Of note, 5% of medication incidents were related to staff communication problems during transfer from theatre or recovery. The researchers believe that categorising patient safety incidents allowed them to make a number of recommendations to improve patient safety in critical care. Thomas AN, et al. Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency. Anaesthesia 63: 726-733, No. 7, Jul 2008 801119785 0114-9954/10/1216-0001/$14.95 Adis © 2010 Springer International Publishing AG. All...