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Iatrogenic intravenous medication errors reported to the PIC Erfurt
Michael Deters1, Dagmar Prasa, Helmut Hentschel
1Poisons Information Center, Erfurt, Germany. michael_deters2002@yahoo.de
Clinical Toxicology (Philadelphia, Pa.)
|July 9, 2008
Summary
Iatrogenic intravenous medication errors (IIME) reported to a poisons center increased over ten years. These medication errors, particularly overdoses, can lead to severe harm, including brain damage and death.
Area of Science:
- Medical Toxicology
- Patient Safety
- Pharmacovigilance
Background:
- Iatrogenic intravenous medication errors (IIME) pose a significant risk to patient safety.
- Understanding the patterns and outcomes of IIME is crucial for developing preventative strategies.
Purpose of the Study:
- To analyze the incidence, characteristics, and outcomes of iatrogenic intravenous medication errors (IIME) reported to the Poisons Information Center (PIC) Erfurt over a decade.
Main Methods:
- Retrospective analysis of all IIME cases reported to PIC Erfurt from 1997 to 2006.
- Categorization of cases by error type, patient age group, involved drugs, and estimated toxicity risk.
Main Results:
- A total of 132 IIME cases were recorded, showing an increasing trend.
- Antipsychotics and antihistamines were the most frequently involved drug classes; overdose and incorrect administration were common error types.
- Over 70% of cases carried a risk of toxicity, with severe outcomes including brain damage and one fatality reported.
Conclusions:
- IIME represent a small but significant proportion of calls to poisons information centers.
- A substantial percentage of IIME cases with known outcomes resulted in severe symptoms, highlighting the potential harm.
- These findings underscore the importance of vigilance and improved practices to prevent harmful medication errors.
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