Incidence and severity of intravenous drug errors in a German hospital

To determine the incidence of errors in preparing and administering intravenous (i.v.) drugs, identify the stages in the process at which errors occurred and evaluate their clinical importance.

A prospective ethnographic study using disguised observation was carried out on two wards in one German non-university hospital.

We observed 22 nurses administering 122 i.v. drug preparations and administrations. One or more errors occurred in the preparation and administration of 58 of 122 i.v. drug doses (error rate 48%, 95% confidence interval 39-57%). In total, 65 errors were identified. Of doses, 4 had potentially severe errors (3%), 38 (31%) potentially moderate errors and 16 (13%) potentially minor errors. Common errors included multiple step preparations and the co-administration of potentially incompatible drugs as intermittent infusions.

A high incidence of i.v. drug errors was found in the study hospital. Effective strategies to reduce potentially harmful errors are urgently needed. Measures could include a reduction in the number of ward-based i.v. drug preparations, improvement of staff training and the introduction of ward-based clinical pharmacy services.