Wrong-route drug administration errors: A review of the literature

Area of Science:

• Pharmacology
• Patient Safety
• Clinical Pharmacy

Background:

• Medication administration errors (MAEs) represent a significant patient safety concern.
• Inadvertent wrong-route administration, such as oral formulations given intravenously or intravenous drugs given intra-arterially, can lead to severe patient harm.
• These errors can result in organ dysfunction and mortality.

Approach:

• This narrative review synthesizes current literature on wrong-route drug administration.
• It explores the underlying pathophysiological mechanisms of harm.
• Preventive strategies and potential therapeutic interventions are investigated.

Key Points:

• Wrong-route administration encompasses diverse scenarios, including oral-to-IV and IV-to-IA errors.
• Pathophysiological consequences vary based on the drug, route, and dose, potentially leading to systemic toxicity or localized ischemia.
• Preventive measures focus on system-based safeguards, including labeling, standardized procedures, and enhanced staff education.

Conclusions:

• Wrong-route drug administration errors pose a serious threat to patient safety.
• Understanding the mechanisms of harm is crucial for developing effective prevention and management strategies.
• Multifaceted approaches involving healthcare professionals, technology, and policy are needed to mitigate these risks.