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Ethnographic study of incidence and severity of intravenous drug errors
1Department of Practice and Policy, School of Pharmacy, University of London, London WC1 1AX. katja.taxis@uni-tuebingen.de
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.