A number of studies have shown high rates of adverse events related to IV administration of medications. Whereas many errors in earlier steps of the medication process may be intercepted before reaching the patient, the administration phase already reaches the patient, thus increasing the potential for serious outcomes.
A new study (Westbrook 2011) from Australia, using direct observation of nurses administering IV medications, found that in almost 70% of cases at least one error was made. Up to a quarter of these were considered potentially serious errors. Most of the errors fell into one of 4 categories and wrong rate was the most frequent. Bolus medications were most problematic.
There was little use of infusion pumps in the settings studied but errors still occurred in cases where such pumps were used.
The experience level of nurses was important. For every year of experience up to 6 years, they noted the risk of error decreased by 11%. After 6 years experience, there was no further change.
Failure to check the identification of the patient occurred in over 50% of cases and was significantly related to increased risk of error. While this was not a cause/effect releationship, the authors felt it likely served as an indicator of general failure to follow correct administration protocols. The authors suggest this variable could be used as a proxy measure for increased risk of clinical error. (Note that this concept is similar to the one in aviation we mentioned in our October 2, 2007 Patient Safety Tip of the Week “Taking Off From the Wrong Runway”in which pilots who routinely violate standard operating procedures such as the “sterile cockpit rule” are three times more likely to make other errors). Fortunately, use of BMV (bedside medication verification) barcoding techniques reduces such failures to identify patients. However, in some settings BMV is bypassed for IV medications or IV infusions.
The authors suggest targets for improvement might include more focus on training and supervision of new nurses doing medication administration, use of fewer bolus medications, and more feedback to all nurses on performance and errors during IV medication administration.
There is also a financial cost to IV medication errors. In our January 22, 2008 Patient Safety Tip of the Week “More on the Cost of Complications” we discussed a study (Nuckols 2008) that demonstrated IV adverse drug events in ICU’s resulted in $6647 higher costs and 4.8 day longer stays compared to control patients in academic ICU’s but no significant difference in cost or LOS in nonacademic ICU’s.
Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf 2011; Published Online First: 20 June 2011
Nuckols TK. MD, Paddock S, Bower AG, Rothschild JM, Fairbanks RJ. Carlson B, Panzer RJ, Hilborne LH. Costs of Intravenous Adverse Drug Events in Academic and Nonacademic Intensive Care Units. Medical Care 2008; 46(1):17-24