Understanding the antibiotic medication use process in the intensive care unit (ICU) is important for patient care outcomes. A system view of the medication use process facilitates understanding the role of communication between various disciplines in ensuring the timely administration of antibiotics. Antibiotic-related medication safety events (N = 312) were collected in two adult ICUs. We describe the information and communication flow in the medication use process and show the complexity of the process. An in-depth analysis of 101 (32%) events for late first-dose antibiotic identifies multiple factors contributing to the events.
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