Background

Health care delivery is not infallible. Errors are common in most health care systems and are reported to be the seventh most common cause of death overall [1]

Every day in hospitals around the world, ampoules and vials in huge numbers are drawn into syringes in the ward by the nursing staff. Unfortunately this often induces different medication errors.

European studies indicate that the rate of errors concerning intravenous administration in hospitals are considerably higher than those involving medicines for oral use. In one study, at least one error occurred in 49.3% of intravenous medicine doses prepared on hospital wards. This particular risk is mainly due to the lack of ready-to-use unit dose packages of injectable pharmaceutical forms on the European market and to inadequate human resources in hospital pharmacies [2].

 

Medication errors:

In an investigation on Herlev Hospital in Denmark, cases of intravenous administration of medicine were observed. There were found 31,7 % deviations, of which 3/4 were deem to have potential clinical importance. Frequent errors were wrong dose and exceeded shelf life of the I.V. solutions [3]

In a study from the UK, one or more errors occurred in the preparation and administration of 212 out of 430 intravenous drug doses (error rate 49%). A total of 249 errors were identified [4].

In a study from Germany one or more errors occurred in the preparation and/or administration of intravenous drug doses with a error rate at 48%. Errors were potentially severe in 3%, potentially moderate in 31%, and potentially minor in 13%. The most common types of error were doses involving multiple-step preparations (wrong solvent/diluent, wrong dose, omission) [5].

In a multinational study with 1328 patients, 861 intravenous medication errors affecting 441 patients were reported for the 24 hour study period. There were 74.5 (95% confidence interval 69.5 to 79.4) errors per 100 patient days. The most frequent errors were related to wrong time of administration (n=386) and missed medication (n=259), followed by wrong dose (n=118), wrong drug (n=61), and wrong route (n=37). Medication errors at the administration stage occurred most frequently during routine situations (n=595; 69%) and least frequently during admission and discharge procedures (n=73; 8%), movement within the hospital (n=40; 5%), undefined situations (n=41; 5%), emergencies (n=38; 4%), interventions (n=36; 4%), and urgent crisis with another patient in the unit (n=29; 3%). Unit staff reported workload/stress/fatigue as a contributing factor in 32% (n=272) of all errors [6].

 

Labeling errors:

A study from UK, Germany and France showed that lack of appropriate labeling was a frequent error. Labeling errors accounted for 118 of 273 observations (43%) in the UK centre, 421 (99%) in the German centre, and 20 (20%) in the French centre. In 55 cases (20%) in the UK hospitals, doses were administered 10 minutes or later after they had been prepared and were not labeled at all. Similarly, in the German wards 171 (40%) of the doses with incomplete labels were not administered immediately after they had been prepared [7].

 

Dilution errors:

At the same study the second most frequent deviation from recommendations was preparing the intravenous doses with the wrong diluent. There were two (1%) such cases in the UK wards, 208 (49%) in the German centre, and 18 (18%) in the French hospital. Other errors included not mixing products adequately as recommended (190 out of 240 (79%) observations in German wards and one (1%) in the French centre) [7].

 

Contamination errors:

In the same study the preparation area was never cleaned in the UK hospitals (0%), it was properly cleaned in 18 (4%) cases in the German wards and in 81 cases (81%) in the French centre. Hands were never washed (0%) in any of the four hospitals in the UK nor were sterile gloves worn, but non-sterile gloves were worn in one hospital in order to protect nurses from the medicines. Hands were washed in the German hospital in 22 cases (5%) and 91 preparations (91%) observed in the French hospital. In the UK centres the tops of vials were wiped with alcohol impregnated swabs in four cases (1%). In the German wards not all nurses considered it important to disinfect the vials, so that it was performed in only 180 (42%) of cases. Vial tops were swabbed in the French hospital in 96 (96%) of cases. In the preparation area either windows were closed or there were no windows at all in the majority of cases (557 of 724 observations (68%) overall in the UK and German centres) [7].