Safe Medication Use in the ICU
Publication Date: September 1, 2017
Last Updated: March 14, 2022
RECOMMENDATIONS
A. ENVIRONMENT AND PATIENTS
1. Environment: ICU Versus Non-ICU
In adult ICU and PICU patients, the severity or harm associated with MEs/ADEs is greater compared to non-ICUs. (Moderate, )
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2. Environment: Safety Culture—Part 1
We suggest implementing changes in the culture of safety to increase the frequency of ME reporting. (Very Low, Weak)
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3. Environment: Safety Culture—Part 2
We suggest implementing changes in the climate and culture of safety to reduce the frequency of MEs or ADEs. (Very Low, Weak)
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4. Environment: Educational Efforts
We suggest including education as part of any comprehensive program to reduce MEs in the ICU. (Low, Weak)
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5. ICU Patients: Risk Factors for ADEs
Adult ICU and PICU patients have different risk factors for ADEs compared to general care patients (non-ICU). (Low, )
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6. ICU Patients: Risk Factors for MEs
Adult and PICU patients have different risk factors for ADEs compared to general care (non-ICU) patients. (Low, )
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B. PRESCRIBING
1. Computer Provider Order Entry (CPOE)
We suggest implementing CPOE to decrease MEs and preventable ADEs. (Moderate, Weak)
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2. CDSS
We suggest the use of CDSS (either electronic or paper format) to decrease the number of MEs/ADEs. (Low, Weak)
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3. Drug Dosing Software
We suggest using computerized drug dosing software to decrease the number of MEs/ADEs for insulin prescribing. (Low, Weak)
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4. Protocols
We suggest the use of protocols/bundles in the ICU to ensure ME/ADE reduction. (Moderate, Weak)
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5. Medication Reconciliation
We make no recommendation regarding the use of medication reconciliation to decrease MEs/ADEs, in ICU patients. (Very Low, No Recommendation)
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6. Broselow—Part 1
The Broselow tape is reliable in predicting patient weight for United States, European, Indian, New Zealand, Filipino, and Korean pediatric populations especially in younger (<3 yr) and lower weight children (<26 kg). (High, )
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7. Broselow—Part 2
We suggest using the Broselow tape in pediatric emergency situations, when patient weight is not available to determine the child’s length and then the associated color-coded, weight-based dosing for emergency drug doses to reduce MEs and ADEs. (Low, Weak)
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C. DISPENSING
1. Automated Packaging of Medications
We suggest installing robotic dispensing systems as a component of the medication dispensing process of solid dosage forms to reduce MEs. (Low, Weak)
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2. Automated Dispensing of Medications
We suggest that the implementation of automation strategies in the medication dispensing process may reduce MEs. (Low, Weak)
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3. Medication Labeling Practices—Sound-Alike Look-Alike Drugs (SALAD)
We suggest using medication labeling practices including tall man lettering for SALAD to reduce the number of MEs. (Moderate, Weak)
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4. Medication Concentration Practices
We recommend compliance with safe medication concentration practices (i.e., use of premade IV preparations, requirement of pharmacists to prepare all IV medications) to reduce the number of MEs and potential ADEs. (Moderate, Strong)
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5. Pharmacist Participation in Medication Passes
We make no recommendation regarding pharmacist involvement in medication passes to reduce the number of ME or ADE due to lack of evidence. (, No Recommendation)
(no evidence)
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6. Independent Double Check During Dispensing
We suggest the use of independent double checks during the dispensing phase for high-risk medications or processes in the ICU to reduce the number of ME. (Low, Weak)
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D. ADMINISTRATION
1. Bar Code Medication Administration
We suggest the use of BCMA to reduce MEs/ADEs in the ICU. (Low, Weak)
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2. Smart Infusion Pumps
We suggest smart IV infusion pumps be used to reduce the rate of MEs/ADEs in the ICU. (Low, Weak)
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3. Double Checking During Medication Administration
We make no recommendation for the inclusion of mandatory double checking during administration of high-risk medications to prevent MEs/ADEs based on the lack of supporting evidence. (Very Low, No Recommendation)
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4. Use of Subjective Assessment Tools
We suggest using validated assessment tools to achieve therapeutic goals during administration/titration of medications in the ICU. (Moderate, Weak)
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E. MONITORING
1. Reflex Laboratory Monitoring
We suggest the use of reflex (automatic) ordering of laboratory values with the addition of a dosing suggestion for heparin orders since there is the potential of avoiding ADEs from this high-risk drug. (Low, Weak)
It is unclear, if this benefit could also be achieved by providing recommendations for heparin dosing suggestions alone without the reflex laboratory monitoring.
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2. Handoff Communication
We make no recommendation for the use of handoff communication technique to prevent MEs/ADEs based on the lack of supporting evidence. (Very Low, No Recommendation)
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3. POC Testing
We make no recommendation for the use of POC testing to prevent MEs/ADEs based on the lack of supporting evidence. (Very Low, No Recommendation)
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4. Patient and Family Members Knowledge of Patient’s Medication Regimen
We make no recommendation regarding notification of medication regimens to the patient or family members to reduce the number of MEs/ADEs due to lack of evidence. (, No Recommendation)
(no evidence)
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F. PATIENT SAFETY SURVEILLANCE SYSTEMS REPORTING
1. Electronic Versus Analog Reporting Systems
We make no recommendation on the use of electronic versus analog systems impacting the quantity or quality of ADE reporting in ICU patients based on the lack of supporting evidence. (Low, No Recommendation)
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G. PATIENT SAFETY SURVEILLANCE SYSTEMS METHODS OF ME AND ADE DETECTION
1. Family and Patient Involvement
We suggest the application of a patient/family reported outcome interview at or after ICU discharge to improve ME/ADE reporting. (Low, Weak)
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2. Nontargeted Chart Review
We suggest performing chart reviews for detecting ADEs as part of a surveillance system. (Low, Weak)
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3. Targeted Chart Review
We suggest the use of trigger-initiated target chart review in addition to voluntary reports to improve the rate of identifying ADEs. (Moderate, Weak)
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4. Trigger Systems—Severe ADEs
We make no recommendation as to benefit of using trigger systems to identify more severe ADEs in critically ill patients compared with alternate detection methods. (Low, No Recommendation)
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5. Direct Observation
We recommend including direct observation as a component of an active medication surveillance system since it provides the advantage of detecting more events and is likely to detect more administration errors than other surveillance methods. (High, Strong)
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H. PATIENT SAFETY SURVEILLANCE SYSTEMS
1. Reliable and Valid ADE Causality Instrument
In adult ICU and PICU patients, a reliable and valid ADE causality assessment instrument can aid in the evaluation of suspected drug-induced events. (Moderate, )
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I. PATIENT SAFETY SURVEILLANCE SYSTEMS METHODS OF EVALUATING DATA
1. Analyzing Reports by ICU and Non-ICU
We suggest performing ICU-specific ADE surveillance and evaluation but evaluation between types of ICU units seems unnecessary to improve the quantity and quality of reporting. (Low, Weak)
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2. Prospective Versus Retrospective Approaches
We make no recommendation on the effectiveness of prospective versus retrospective strategies at detecting MEs/ADEs in medication safety surveillance. (Very Low, No Recommendation)
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3. Benchmarking
We make no recommendation on the effectiveness of benchmarking for patient safety surveillance strategies on improving outcomes such as ME/ADE rate. (, No Recommendation)
(no evidence)
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4. Compliance With Safety Standards
We make no recommendation on the effectiveness of strict compliance with patient safety standards set forth by regulatory bodies on impacting outcomes such as ME/ADE rates. (, No Recommendation)
(no evidence)
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Recommendation Grading
Overview
Title
Safe Medication Use in the ICU
Authoring Organization
Society of Critical Care Medicine
Publication Month/Year
September 1, 2017
Last Updated Month/Year
January 17, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill.
Target Patient Population
Critically ill patients
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Infant, Older adult
Health Care Settings
Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management
Diseases/Conditions (MeSH)
D003422 - Critical Care, D016638 - Critical Illness, D007362 - Intensive Care Units, D061214 - Patient Safety, D017751 - Safety Management, D008508 - Medication Errors, D064420 - Drug-Related Side Effects and Adverse Reactions
Keywords
critical care, critical illness, intensive care unit, medication safety
Source Citation
Critical Care Medicine: September 2017 - Volume 45 - Issue 9 - p e877-e915
doi: 10.1097/CCM.0000000000002533
Supplemental Methodology Resources
Methodology
Number of Source Documents
374
Literature Search Start Date
March 1, 2013
Literature Search End Date
December 1, 2015