Errors Associated with IV Infusions in Critical Care.

Area of Science:

• Patient Safety
• Medication Administration
• Healthcare Quality Improvement

Background:

• Intravenous (IV) medication errors often lead to severe patient outcomes.
• IV medications are linked to a significant proportion of adverse events and medication errors.

Purpose of the Study:

• To identify the types and frequency of errors in IV infusion prescribing, documentation, and administration.
• To investigate potential correlations between error incidence and time of day or day of the week.
• To assess IV infusion errors in an academic medicosurgical intensive care unit (ICU) lacking computerized order entry.

Main Methods:

• A prospective, observational audit of IV infusions in critically ill patients.
• Data collected over 7 months (2007) during 40 randomly selected shifts.
• Error identification through direct observation, medication administration records, and patient charts.

Main Results:

• Up to 21 distinct errors per IV medication dose were possible.
• A total of 5641 errors were identified across 1882 IV infusions.
• Documentation errors (omissions, discrepancies) constituted 92.7% of all identified errors.

Conclusions:

• Direct observation and strict error definitions effectively identified errors throughout the IV medication administration process.
• Documentation discrepancies were the most common errors in this paper-based system.
• Findings highlight critical areas for improvement in IV medication safety.