| This study describes the communication that occurred when there was a medication error in the adult intensive care unit, including breakdowns in communication that contribute to medication error and communication that occurs after a medication error. Communication after a medication error may be good (communication to recover from the error) or bad (an additional breakdown in communication).;A secondary data analysis of antibiotic medication safety event data was performed to answer the research question and develop a model of communication in the medication use process and its impact on medication safety. The medication safety event data used in the secondary analysis were collected on the Adult ICU (AICU) and Cardiac ICU (CICU) at Geisinger Medical Center. The Salas et al (2008) three-pronged approach to teamwork model was used as a framework for classifying communication and its role in medication safety during the secondary analysis of antibiotic medication event data.;For the 377 events with sufficient information to describe the communication that occurred, nearly all of the events (100%) included content about information in the medication order (e.g., dose, route, frequency, duration). There were 14 methods of written communication used, as well as verbal conversation. Nearly all events involved asynchronous information transfer (99%) and sequential information transfer steps (100%). The people involved in communication were most frequently a pharmacist (85%), physician (65%), or nurse (40%). The pathways by which communication related to medication error were communication breakdowns leading to error (pathway A) in 93% of events and communication after an error (pathway B) in 68% of events. These pathways may occur singly, but were most often observed in combination (61% of events). There were 42 distinct communication network diagrams depicting the information flow before and after the medication error created as part of this study. |
