Mediation Error: Half of Intravenous Drug Doses are Wrong

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.

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.

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