Preventing narcotic adverse events in critical care units.

The recently published Canadian Adverse Events Study found that 7.5% of patients admitted to hospital had experienced an adverse event, 36.9% of adverse events were considered to be “highly preventable” and 23.6% of all adverse events were ”drugor fluid-related” (Baker et al., 2004). The researchers defined an adverse event “as an unintended injury or complication that results in disability at the time of discharge, death or prolonged hospital stay and that is caused by health care management rather than by the patient’s underlying disease process” (Baker et al., 2004, p.1679). This is the largest study in Canada on adverse events, reviewing 3,745 charts in the fiscal year 2000 from a total of 20 acute care hospitals across five provinces. Health care is a complex and high-risk industry, and a 92.5% rate of doing things right might be perceived by some as acceptable and as an indicator of a relatively safe system. However, in other high-risk areas, such as the airline industry, this rate would be unacceptable. For instance, it has been calculated that a 99.9% accuracy rate would mean two unsafe plane landings per day at Chicago’s O’Hare airport (Baker, 2001). Improved safety in the health care system can occur with small steps and incremental improvements. Focusing on high-alert drugs, such as narcotics, is an area where health care professionals can influence change.