Causes of intravenous medication errors: an ethnographic study

Taxis, Katja; Barber, Nick

doi:10.1136/qhc.12.5.343

Cited by 211 publications

(262 citation statements)

References 27 publications

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“…doses. 38 An error rate of 73% was identified with bolus doses, which were given faster than the recommended time of three to five minutes. Lack of knowledge of preparation and administration and complex design of equipment were cited as the causes of the errors.…”

Section: IV Medicationsmentioning

confidence: 99%

Current status of administration of medicines

Shane

2009

American Journal of Health-System Pharmacy

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Section: IV Medicationsmentioning

confidence: 99%

Current status of administration of medicines

Shane

2009

American Journal of Health-System Pharmacy

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“…Taxis and Barber 7 have shown that about half of all ward-based intravenous drug preparations and administrations are incorrect. These incompatibilities produce about 20% of all medication errors and almost 89% of the overall errors in the administration of drugs 8,12 . The aim of this study was to survey the incidence and extent of the incompatibilities in a hospital in the Czech Republic and in Eastern Europe with the ultimate goal of making recommendations for reducing the risk of incompatibilities.…”

Section: Introductionmentioning

confidence: 99%

Incidence of intravenous drug incompatibilities in intensive care units

Machotka¹,

Man̆ák²,

Kubêna³

et al. 2015

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub

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Aims. Drug incompatibilities are relatively common in inpatients and this may result in increased morbidity/mortality as well as add to costs. The aim of this 12 month study was to identify real incidences of drug incompatibilities in intravenous lines in critically ill patients in two intensive care units (ICUs). Methods. A prospective cross sectional study of 82 patients in 2 ICUs, one medical and one surgical in a 1500-bed university hospital. One monitor carried out observations during busy hours with frequent drug administration. Patients included in both ICUs were those receiving at least two different intravenous drugs. Results. 6.82% and 2.16% of drug pairs were found to be incompatible in the two ICUs respectively. Among the most frequent incompatible drugs found were insulin, ranitidine and furosemide. Conclusions:The study showed that a significant number of drug incompatibilities occur in both medical and surgical ICUs. It follows that the incidence of incompatibilities could be diminished by adhering to a few simple rules for medication administration, following by recommendations for multiple lumen catheter use. Future prospective studies should demonstrate the effect of applying these policies in practice.

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“…Ward-based preparation of injectables is a high-risk process and the multiple steps in the procedure provide many opportunities for human error (26,27) . In a recent observational study there were one or more errors detected in 49% of intravenous doses (28) . In an analysis of observational studies, the most common errors were diluent selection and reconstitution, administration (particularly injection or infusion rate) and confirmation of allergy status (29) .…”

Section: The Balance Of Risks: Ward-based V Pharmacy-based Preparationmentioning

confidence: 97%

Quality parenteral nutrition: an ideal mixed bag

White

2011

Proc. Nutr. Soc.

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Professor Pennington was an advocate for quality in all aspects of nutrition support and its delivery, ensuring that the patient remained at the centre of all decisions, and that specialist artificial nutrition support was best managed by the multidisciplinary nutrition team and the education of the wider healthcare community. Within the conference theme of 'Quality', this commentary aims to outline drivers for and risks to aspects of quality in parenteral nutrition (PN) services. Quality is defined as a particular property or attribute associated with excellence; in the context of the provision of PN this can be translated to quality processes and standards in the assessment, prescription, preparation, administration and monitoring of PN. Quality products and services are delivered through the timely application of knowledge, competence, procedures and standards. Quality can be so easily compromised; inattention, ignorance and arrogance all play their part. PN is a high-risk therapy; the quality of its delivery should not be entirely dependent on the skills, knowledge and competence of those delivering this care but on accepted standards, procedures, communication, resource and infrastructure. Identification of key steps in the provision of PN and a review of the relevant patient safety data reveal points where safeguards can be put in place to ensure quality is not compromised. Full evaluation of standardisation, computerisation and competency-based training as risk-reduction strategies is required.

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Causes of intravenous medication errors: an ethnographic study

Cited by 211 publications

References 27 publications

Current status of administration of medicines

Current status of administration of medicines

Incidence of intravenous drug incompatibilities in intensive care units

Quality parenteral nutrition: an ideal mixed bag

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