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Causes of intravenous medication errors: an ethnographic study
  1. K Taxis,
  2. N Barber
  1. Department of Practice and Policy, The School of Pharmacy, University of London, London WC1N 1AX, UK
  1. Correspondence to:
 Dr K Taxis, Pharmazeutische Biologie, Pharmazeutisches Institut, Universitaet Tuebingen, Auf der Morgenstelle 8, 72076 Tuebingen, Germany; 
 katja.taxis{at}uni-tuebingen.de

Abstract

Background: Intravenous (IV) medication errors are frequent events. They are associated with considerable harm, but little is known about their causes. Human error theory is increasingly used to understand adverse events in medicine, but has not yet been applied to study IV errors. Our aim was to investigate causes of errors in IV drug preparation and administration using a framework of human error theory.

Methods: A trained and experienced observer accompanied nurses during IV drug rounds on 10 wards in two hospitals (one university teaching hospital and one non-teaching hospital) in the UK. Information came from observation and talking informally to staff. Human error theory was used to analyse the causes of IV error.

Results: 265 IV drug errors were identified during observation of 483 drug preparations and 447 administrations. The most common type of error was the deliberate violation of guidelines when injecting bolus doses faster than the recommended speed of 3–5 minutes. Causes included a lack of perceived risk, poor role models, and available technology. Mistakes occurred when drug preparation or administration involved uncommon procedures such as the preparation of very small volumes or the use of unusual drug vial presentations. Causes included a lack of knowledge of preparation or administration procedures and complex design of equipment. Underlying problems were the cultural context allowing unsafe drug use, the failure to teach practical aspects of drug handling, and design failures.

Conclusions: Training needs and design issues should be addressed to reduce the rate of IV drug preparation and administration errors. This needs a coordinated approach from practitioners, regulators, and the pharmaceutical industry.

  • human error theory
  • medication errors
  • intravenous treatment
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Footnotes

  • See editorial commentary, pp 326–7

  • This study was funded by The School of Pharmacy, University of London. The sponsors had no influence on study design, data collection, data analysis, data interpretation, or writing of the report.

  • The study was designed by both authors. KT collected the data and analysed it with NB. The final report was written by both authors.

  • Conflict of interest: none declared.

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