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Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using
R E Ferner1, N J Langford, C Anton
1West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH, UK. r.e.ferner@bham.ac.uk
British Journal of Clinical Pharmacology
|December 12, 2001
Summary
Errors in intravenous infusion dosing are common, with many drug doses deviating significantly from the intended amount. This study highlights the need for improved quality control in medication administration to ensure patient safety.
Area of Science:
- Clinical Pharmacy
- Medication Safety
- Intravenous Infusions
Background:
- Previous error estimation relied on observers or retrospective analysis.
- Routine clinical practice offers a novel approach to assess medication errors.
- Intravenous drug administration, especially with complex schedules, is prone to errors.
Purpose of the Study:
- To prospectively examine the accuracy of drug concentrations in intravenous infusions.
- To identify the incidence and nature of dosing errors in routine clinical practice.
- To evaluate the delivered dose of acetylcysteine for acetaminophen overdose.
Main Methods:
- Prospective collection of infusion samples from 66 patients in the UK.
- Measurement of acetylcysteine concentrations in infusion bags.
- Calculation of the percentage of the anticipated dose administered based on patient weight.
Main Results:
- Only 37% of infusion bags had doses within 10% of the intended amount.
- 61% of bags were within 20% of the intended dose.
- Significant deviations (>50%) occurred in 9% of infusions, with systematic errors in some patients.
Conclusions:
- Significant random variation exists in administered intravenous infusion doses.
- Systematic calculation errors, drawing-up errors, and inadequate mixing contribute to dosage deviations.
- Despite complex regimens, quality control methods are essential to minimize deviations between intended and delivered drug doses.