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Medication errors involving wrong administration technique.

John P Santell1, Diane D Cousins

  • 1Educational Program Initiatives, United States Pharmacopeia, Center for the Advancement of Patient Safety, Rockville, Maryland, USA. jps@usp.org

Joint Commission Journal on Quality and Patient Safety
|November 1, 2005
PubMed
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Improper medication administration techniques are a major cause of patient harm. Enhancing healthcare staff education on correct procedures can significantly reduce these medication errors.

Area of Science:

  • Healthcare quality and safety
  • Nursing practice
  • Medication management

Background:

  • Administration technique errors are a significant source of medication errors in healthcare.
  • These errors frequently occur during medication administration on patient care units, primarily involving nurses.
  • Errors can also happen in other medication use phases and involve various healthcare personnel and settings.

Observation:

  • Performance deficits, procedural non-adherence, and knowledge gaps are leading causes of administration errors.
  • Nurses are most frequently implicated in these errors during patient care.
  • Errors span across different stages of medication use and involve diverse healthcare professionals.

Findings:

  • Wrong administration techniques are consistently among the most harmful medication errors.

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  • Commonly reported causes include performance deficits, failure to follow protocols, and knowledge deficits.
  • Specific drug products are frequently associated with administration errors and patient harm.

    • Implications:

    • Targeted education and training on proper administration techniques are crucial for risk reduction.
    • Training should cover the correct use of infusion pumps and dispensing devices.
    • Focusing educational efforts on high-risk drug products can further mitigate harm.