The Pharmaceutical Journal
Vol 270 No 7242 p425
29 March 2003

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BMJ (bmj.com)

Many IV drug orders end in error

As many as half of all intravenous (IV) drug doses given in hospital are associated with an error, new research suggests (BMJ 2003;326:684). The findings also show that most errors associated with IV drug doses occur when giving bolus doses or making up drugs that require multiple step preparation.

Katja Taxis and Professor Nick Barber, from the department of practice and policy, School of Pharmacy, University of London, collected data on the number, type and importance of errors in the preparation and administration of IV drugs over six to 10 days on 10 wards in two British hospitals.

At least one error occurred in the preparation or administration of 212 of 430 IV drug doses (49 per cent, 95 per cent confidence interval 45 per cent to 54 per cent). The mistakes associated with three (1 per cent) of the doses had potentially severe consequences, 126 (29 per cent) had potentially moderate consequences, and 83 (19 per cent) had potentially minor consequences. "Our data suggest that at least one patient will experience a potentially serious intravenous drug error every day in a [400-bed] hospital," they say.

Preparation errors occurred in 32 doses (7 per cent), administration errors in 155 doses (36 per cent), and both types of error in 25 doses (6 per cent).

Possible strategies for reducing risks include centralised preparation of IV drugs by pharmacy staff and purchase of ready prepared IV drugs. However, the researchers point out that the evidence for centralised services is weak and that new types of errors could be introduced with these strategies. The researchers also suggest that the use of technology that prevents fast administration of bolus doses and staff training could improve error rates.