Errors occur in half of intravenous drug doses

It has been widely reported that medication errors – including prescribing the wrong drug, incorrect dosages, or negative interactions between two or more drugs – account for many of the medical adverse events that kill close to 100,000 people each year. Most of these drug errors involve pills prescribed to people in doctor’s offices or hospitals.

Now, a report by BMJ (formerly, British Medical Journal), reveals that people who receive intravenous drug in hospitals may be at an even greater risk. According to the report, errors occurred in almost half of the intravenous drug doses given at the hospitals studied. Preparation errors occurred in 32 doses (7%), administration errors in 155 doses (36%), and both types of error in 25 doses (6%). Errors were potentially harmful in about a third of cases.

Data were collected on the number, type, and clinical importance of errors in the preparation and administration of intravenous drugs over 6-10 consecutive days on 10 wards in two U.K. hospitals. A total of 1,042 doses were prescribed for 106 patients during the study.

The most common errors were giving concentrated (bolus) doses too quickly and mistakes in preparing drugs that required multiple steps.

SOURCE: “Ethnographic study of incidence and severity of intravenous drug errors, BMJ, Volume 326, pp 684-6, March 2003.