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Causes of intravenous medication errors—observation of nurses in a German hospital

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Abstract

Aim

Errors in the preparation and administration of intravenous (IV) drugs are frequent events. Human error theory has recently been applied to understand the causes of IV drug errors in an ethnographic study in the United Kingdom. We used this approach to explore causes of IV drug errors by nursing staff in a German hospital.

Methods

A trained and experienced observer accompanied nurses during IV drug rounds on two wards in one German hospital. Information came from observation and talking informally to staff. Human error theory was used to analyse causes of IV errors.

Results

Twenty-two nurses were observed for 13 study days. A total of 74 IV drug errors were identified while observing 161 preparations and 135 administrations. Mistakes were frequently related to the selection of the wrong fluid for drug preparation and the co-administration of potentially incompatible infusions. Lack of training in IV drug preparation and administration was the main problem. Furthermore, guidelines were ambiguous and did not contain sufficient information. The transcription of drug orders also contributed to drug errors.

Conclusion

The introduction of nurse training and guidelines provided by a multidisciplinary team, including a clinical pharmacist, may reduce the high rate of IV drug errors. These measures should be linked to a review of the legal framework to recognise IV drug administration as a nursing task.

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Acknowledgements

KT received a grant from the School of Pharmacy, University of London and from the Central Research Fund, University of London. We thank the staff of the study hospital for their enthusiastic support.

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Correspondence to Katja Taxis.

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Taxis, K., Barber, N. Causes of intravenous medication errors—observation of nurses in a German hospital. J Public Health 12, 132–138 (2004). https://doi.org/10.1007/s10389-004-0019-4

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