Ethnographic study of incidence and severity of intravenous drug errors.
Taxis K, Barber N.
Department of Practice and Policy, School of Pharmacy, University of London, London WC1 1AX.
[email protected]
OBJECTIVES: To determine the incidence and clinical importance of errors in the preparation and administration of intravenous drugs and the stages of the process in which errors occur.
DESIGN: Prospective ethnographic study using disguised observation.
PARTICIPANTS: Nurses who prepared and administered intravenous drugs.
SETTING: 10 wards in a teaching and non-teaching hospital in the United Kingdom.
MAIN OUTCOME MEASURES: Number, type, and clinical importance of errors. RESULTS: 249 errors were identified. At least one error occurred in 212 out of 430 intravenous drug doses (49%, 95% confidence interval 45% to 54%). Three doses (1%) had potentially severe errors, 126 (29%) potentially moderate errors, and 83 (19%) potentially minor errors. Most errors occurred when giving bolus doses or making up drugs that required multiple step preparation.
CONCLUSIONS: The rate of intravenous drug errors was high. Although most errors would cause only short term adverse effects, a few could have been serious. A combination of reducing the amount of preparation on the ward, training, and technology to administer slow bolus doses would probably have the greatest effect on error rates.