Ethnographic study of incidence and severity of intravenous drug errors

doi:10.1136/bmj.326.7391.684

BMJ 2003;326:684 ( 29 March )

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Ethnographic study of incidence and severity of intravenous drug errors

Katja Taxis, assistant professor in pharmacy, Nick Barber, professor of the practice of pharmacy.

Department of Practice and Policy, School of Pharmacy, University of London, London WC1 1AX

Correspondence to: K Taxis, Pharmazeutische Biologie, Pharmazeutisches Institut, Universität Tübingen, Auf der Morgenstelle 8, 72076 Tübingen, Germany katja.taxis{at}uni-tuebingen.de

Objectives: To determine the incidence and clinical importanceof errors in the preparation and administration of intravenousdrugs and the stages of the process in which errorsoccur.
Design: Prospective ethnographic study using disguisedobservation.
Participants: Nurses who prepared and administered intravenousdrugs.
Setting: 10 wards in a teaching and non-teaching hospitalin the UnitedKingdom.
Main outcome measures: Number, type, and clinical importance oferrors.
Results: 249 errors were identified. At least one erroroccurred in 212 out of 430 intravenous drug doses (49%, 95% confidenceinterval 45% to 54%). Three doses (1%) had potentially severeerrors, 126 (29%) potentially moderate errors, and 83 (19%) potentiallyminor errors. Most errors occurred when giving bolus doses ormaking up drugs that required multiple steppreparation.
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 amountof preparation on the ward, training, and technology to administerslow bolus doses would probably have the greatest effect on errorrates.

What is already known on this topic
Errors in preparing and administering intravenous drugs can cause considerable harm to patients

Reduction of drug errors is a government health target in the United Kingdom and the United States

What this study adds
Errors occurred in about half of the intravenous drug doses observed

Errors were potentially harmful in about a third of cases

The most common errors were giving bolus doses too quickly and mistakes in preparing drugs that required multiple steps

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