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Qual Saf Health Care. Oct 2003; 12(5): 343–347.
PMCID: PMC1743768

Causes of intravenous medication errors: an ethnographic study


Background: Intravenous (IV) medication errors are frequent events. They are associated with considerable harm, but little is known about their causes. Human error theory is increasingly used to understand adverse events in medicine, but has not yet been applied to study IV errors. Our aim was to investigate causes of errors in IV drug preparation and administration using a framework of human error theory.

Methods: A trained and experienced observer accompanied nurses during IV drug rounds on 10 wards in two hospitals (one university teaching hospital and one non-teaching hospital) in the UK. Information came from observation and talking informally to staff. Human error theory was used to analyse the causes of IV error.

Results: 265 IV drug errors were identified during observation of 483 drug preparations and 447 administrations. The most common type of error was the deliberate violation of guidelines when injecting bolus doses faster than the recommended speed of 3–5 minutes. Causes included a lack of perceived risk, poor role models, and available technology. Mistakes occurred when drug preparation or administration involved uncommon procedures such as the preparation of very small volumes or the use of unusual drug vial presentations. Causes included a lack of knowledge of preparation or administration procedures and complex design of equipment. Underlying problems were the cultural context allowing unsafe drug use, the failure to teach practical aspects of drug handling, and design failures.

Conclusions: Training needs and design issues should be addressed to reduce the rate of IV drug preparation and administration errors. This needs a coordinated approach from practitioners, regulators, and the pharmaceutical industry.

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Selected References

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  • Taxis Katja, Barber Nick. Ethnographic study of incidence and severity of intravenous drug errors. BMJ. 2003 Mar 29;326(7391):684–684. [PMC free article] [PubMed]
  • O'Hare MC, Bradley AM, Gallagher T, Shields MD. Errors in administration of intravenous drugs. BMJ. 1995 Jun 10;310(6993):1536–1537. [PMC free article] [PubMed]
  • Wirtz Veronika, Taxis Katja, Barber Nick D. An observational study of intravenous medication errors in the United Kingdom and in Germany. Pharm World Sci. 2003 Jun;25(3):104–111. [PubMed]
  • Dyer C. Doctors cleared of manslaughter. BMJ. 1999 Jan 16;318(7177):148–148. [PMC free article] [PubMed]
  • Hannah Mary E. Series of errors. Lancet. 2002 Oct 26;360(9342):1322–1322. [PubMed]
  • Leape LL. Error in medicine. JAMA. 1994 Dec 21;272(23):1851–1857. [PubMed]
  • Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984 Jan;60(1):34–42. [PubMed]
  • Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey R, Ives J, Laird N, Laffel G, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):35–43. [PubMed]
  • Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, Tizzard A. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000 Mar 18;320(7237):777–781. [PMC free article] [PubMed]
  • Dean Bryony, Schachter Mike, Vincent Charles, Barber Nick. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002 Apr 20;359(9315):1373–1378. [PubMed]
  • Stanhope N, Vincent C, Taylor-Adams SE, O'Connor AM, Beard RW. Applying human factors methods to clinical risk management in obstetrics. Br J Obstet Gynaecol. 1997 Nov;104(11):1225–1232. [PubMed]
  • Taxis K, Dean B, Barber N. Hospital drug distribution systems in the UK and Germany--a study of medication errors. Pharm World Sci. 1999 Feb;21(1):25–31. [PubMed]
  • Savage J. Ethnography and health care. BMJ. 2000 Dec 2;321(7273):1400–1402. [PMC free article] [PubMed]
  • Mays N, Pope C. Qualitative research: Observational methods in health care settings. BMJ. 1995 Jul 15;311(6998):182–184. [PMC free article] [PubMed]
  • Barber N, Smith F, Anderson S. Improving quality of health care: the role of pharmacists. Qual Health Care. 1994 Sep;3(3):153–158. [PMC free article] [PubMed]
  • Dean B, Barber N. Validity and reliability of observational methods for studying medication administration errors. Am J Health Syst Pharm. 2001 Jan 1;58(1):54–59. [PubMed]
  • Campbell T, Lunn D. Intravenous therapy: current practice and nursing concerns. Br J Nurs. 6(21):1218–1228. [PubMed]
  • Wilkinson R. Nurses' concerns about i.v. therapy and devices. Nurs Stand. 1996 May 22;10(35):35–37. [PubMed]
  • Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000 Dec;83(6):492–497. [PMC free article] [PubMed]
  • Armour DJ, Cairns CJ, Costello I, Riley SJ, Davies EG. The economics of a pharmacy-based central intravenous additive service for paediatric patients. Pharmacoeconomics. 1996 Oct;10(4):386–394. [PubMed]
  • Ferner RE. Misleading drug packaging. BMJ. 1995 Aug 19;311(7003):514–514. [PMC free article] [PubMed]
  • Malhotra A, Matson M, Chan O. Not again! Packaging of lignocaine must be changed. BMJ. 2001 Mar 3;322(7285):549–549. [PubMed]
  • Obradovich JH, Woods DD. Users as designers: how people cope with poor HCI design in computer-based medical devices. Hum Factors. 1996 Dec;38(4):574–592. [PubMed]
  • Rappaport M. Human factors applications in medicine. Hum Factors. 1970 Feb;12(1):25–35. [PubMed]

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