Table 3

Examples of observed deviations in the administration of intravenous infusions

Severity categoryExamples
  • Patient was administered 2 g vancomycin diluted in 250 mL of sodium chloride 0.9%. The drug should have been diluted in 500 mL of sodium chloride 0.9% (concentration error: severity category E) and administered over at least 240 min. The drug was observed running too fast via gravity feed (rate error: D). The chart had not been signed to confirm the administration had been double-checked as required (documentation discrepancy: A2). The patient suffered from pain and red lumps along arm.

  • Piperacillin/tazobactam was prescribed to be given over 3 hours. However, it was given as a bolus over 3–5 min, which is the most common way to administer this antibiotic. The nurses presumed the doctors had made a mistake and corrected it. However, this had been prescribed intentionally after discussions with the consultant, with microbiology, with pharmacy and the drug manufacturer due to the patient’s poor renal function. This clinical decision was recorded in the patient’s notes but nursing staff had not reviewed these.

  • 40 mmol of potassium chloride rather than the prescribed 20 mmol was administered together with 10 mmol magnesium sulfate in sodium chloride 0.9% at 1000 mL/hour.

  • 1 L sodium chloride 0.9% with potassium chloride 0.15% was prescribed over 12 hours. The documented start time was 23:25. When observed at 13:00 the following day the infusion was not running and approximately 150 mL remained. The infusion should have been complete but the pump was not plugged in and the battery was empty.

  • A medication order for 20 mcg fentanyl stated diluent as dextrose 5%, however the drug was prepared and administered in sodium chloride 0.9%.

  • Electronic prescription specified 1 L of sodium chloride 0.9% over 8 hours. Started at 02:00 thus due to finish 10:00 but at 09:25 there was still 500 mL to run. The infusion was paused at the time of observation as the patient was receiving an intermittent amoxicillin infusion.

  • Hartmann’s solution had been selected in the smart pump’s drug library but the infusion being administered was sodium chloride 0.9% (at the correct rate prescribed).

  • The prescribed rate was 250 mL/hour for 123 mg paclitaxel in 250 mL sodium chloride 0.9%. However, the final reconstituted volume was 290.5 mL, which was being infused at 290 mL/hour to give the same rate of administration as prescribed.

  • Administration of piperacillin/tazobactam was delayed by approximately 30 min.