Iatrogenic intravenous medication errors reported to the PIC Erfurt

Abstract

Approximately 0.1% of all calls registered by the PIC Erfurt from 1997 to 2006 concerned IIME. Thirty-two percent of IIME followed to a known outcome resulted in severe symptoms. These data show that IIME can be harmful.

Medication wrong route administration: a poisons center-based study

“…Actually, two studies from Germany (only intravenous wrong route) found a frequency of 0.03% [9] and 0.01% [10], respectively, a Finnish study (erroneous route in general) of 0.04% [20], and an Irish study (erroneous route in general) of 0.5% [21]. Nevertheless, a detailed analysis is important and appropriate since every case may deliver new insights into the circumstances of occurrence, resulting symptoms, treatment options, and outcomes, and therefore enable the identification of at-risk situations, with the subsequent possibility to implement effective prevention strategies.…”

“…Furthermore, previous studies have shown that medication errors encompass different types such as wrong medication, wrong dose, wrong time, and wrong route [6][7][8]. Within the latter group, parenteral administration errors are particularly relevant because of the potential risk for serious outcomes [9][10][11]. However, information in the literature about the circumstances and consequences of application of medicines by the wrong route is limited and mostly based on single case reports for most specialties.…”

“…Furthermore, the potential reluctance of health care professionals to report such events may be mitigated by the fact that PCs are not enforcement authorities, and therefore health care providers do not have to be concerned about disciplinary actions and medico-legal liability. Nevertheless, it is possible that a substantial number of wrong route application cases remain unreported, because medical errors are a delicate issue and health professionals may be unwilling to provide information [9,16]. Furthermore, it has been suggested that PCs are more likely to be contacted in severe cases [9,10], so that mild and moderate cases may be underrepresented in analyses based on PCs data.…”

“…Nevertheless, it is possible that a substantial number of wrong route application cases remain unreported, because medical errors are a delicate issue and health professionals may be unwilling to provide information [9,16]. Furthermore, it has been suggested that PCs are more likely to be contacted in severe cases [9,10], so that mild and moderate cases may be underrepresented in analyses based on PCs data.…”

“…In contrast, in oncology, where parenteral administration of highly toxic substances is frequent, a number of publications have addressed this issue [12][13][14].Some of the studies on medication errors were performed by poisons centres (PCs), which are reference centres in case of poisoning and medication-related problems and often cover a referral population in the range of some million people. PCs therefore exert also a centralizing function in collecting and documenting cases of administration errors of medications and medicinal products, and in assisting clinicians in the management of these events [9,10,15]. Furthermore, the potential reluctance of health care professionals to report such events may be mitigated by the fact that PCs are not enforcement authorities, and therefore health care providers do not have to be concerned about disciplinary actions and medico-legal liability.…”