Causes of intravenous medication errors: an ethnographic study.

Area of Science:

• Medical Safety
• Human Factors Engineering
• Pharmacology

Background:

• Intravenous (IV) medication errors are frequent and harmful, yet their causes are poorly understood.
• Human error theory offers a framework for analyzing adverse events but has not been applied to IV errors.
• This study investigates the root causes of IV drug preparation and administration errors.

Purpose of the Study:

• To apply human error theory to identify the causes of IV medication errors.
• To analyze the factors contributing to errors in both the preparation and administration phases of IV drugs.
• To provide insights for improving patient safety in IV medication practices.

Main Methods:

• An observational study was conducted on 10 wards across two UK hospitals.
• Trained observers accompanied nurses during IV drug rounds, collecting data through direct observation and informal discussions.
• Human error theory was utilized as the analytical framework for understanding identified errors.

Main Results:

• 265 IV drug errors were documented during the observation of 483 drug preparations and 447 administrations.
• The most frequent error involved deliberate guideline violations, such as injecting bolus doses too rapidly.
• Mistakes also occurred during complex procedures, stemming from a lack of knowledge or equipment design flaws.

Conclusions:

• Identified causes of IV errors include perceived lack of risk, poor role modeling, and technological limitations.
• Underlying issues involve unsafe drug use culture, inadequate practical training, and design failures.
• Recommendations focus on improving training and addressing design flaws through a coordinated effort by practitioners, regulators, and industry.