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Nurs Stand. 2008 Jun 4-10;22(39):35-42.

Vancomycin administration: mistakes made by nursing staff.

Author information

  • 1School of Nursing, Federal University of the State of Rio Grande do Sul State, Brazil. S.E.Jordan@swansea.ac.uk

Abstract

AIM:

To identify the number and types of errors made by assistant and technical nurses when administering intravenous (IV) vancomycin.

METHOD:

Preparation and IV administration of 143 doses of vancomycin by 55 assistant and technical nurses were observed in four acute wards (three adult and one paediatric) in a public university hospital in Brazil. Non-participant observers completed a structured checklist for each dose.

RESULTS:

A total of 27 (19%) doses were administered correctly and 116 (81%) incorrectly. There were 268 errors of four types: (i) incorrect dose; (ii) improper preparation of a dose; (iii) inadequate administration technique; and (iv) infusion at an incorrect rate. For 13 of 143 (9%) doses, errors occurred in all four aspects of administration. Errors were observed on all four wards.

CONCLUSION:

The high incidence of suboptimal administration of vancomycin observed is a cause for concern. Focused education and safety measures have been introduced and their impact is being evaluated.

PMID:
18578131
[PubMed - indexed for MEDLINE]
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