PubMed · 12654416
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Ralf Bender, Oliver Kuss. 2003. Confidence intervals for adjusted NNEs: a simulation study.. https://doi.org/10.1016/s0895-4356(02)00579-6
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OBJECTIVES: To determine the incidence and clinical importance of errors in the preparation and administration of intravenous drugs and the stages of the process in which errors occur. DESIGN: Prospective ethnographic study using disguised observation. PARTICIPANTS: Nurses who prepared and administered intravenous drugs. SETTING: 10 wards in a teaching and non-teaching hospital in the United Kingdom. MAIN OUTCOME MEASURES: Number, type, and clinical importance of errors. RESULTS: 249 errors were identified. At least one error occurred in 212 out of 430 intravenous drug doses (49%, 95% confidence interval 45% to 54%). Three doses (1%) had potentially severe errors, 126 (29%) potentially moderate errors, and 83 (19%) potentially minor errors. Most errors occurred when giving bolus doses or making up drugs that required multiple step preparation. CONCLUSIONS: The rate of intravenous drug errors was high. Although most errors would cause only short term adverse effects, a few could have been serious. A combination of reducing the amount of preparation on the ward, training, and technology to administer slow bolus doses would probably have the greatest effect on error rates.
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