Systematic evaluation of errors occurring during the preparation of intravenous medication

Abstract

Introduction: Errors in the concentration of intravenous medications are not uncommon. We evaluated steps in the infusion-preparation process to identify factors associated with preventable medication errors.

Methods: We included 118 health care professionals who would be involved in the preparation of intravenous medication infusions as part of their regular clinical activities. Participants performed 5 infusion-preparation tasks (drug-volume calculation, rounding, volume measurement, dose-volume calculation, mixing) and prepared 4 morphine infusions to specified concentrations. The primary outcome was the occurrence of error (deviation of > 5% for volume measurement and > 10% for other measures). The secondary outcome was the magnitude of error.

Results: Participants performed 1180 drug-volume calculations, 1180 rounding calculations and made 1767 syringe-volume measurements, and they prepared 464 morphine infusions. We detected errors in 58 (4.9%, 95% confidence interval [CI] 3.7% to 6.2%) drug-volume calculations, 30 (2.5%, 95% CI 1.6% to 3.4%) rounding calculations and 29 (1.6%, 95% CI 1.1% to 2.2%) volume measurements. We found 7 errors (1.6%, 95% CI 0.4% to 2.7%) in drug mixing. Of the 464 infusion preparations, 161 (34.7%, 95% CI 30.4% to 39%) contained concentration errors. Calculator use was associated with fewer errors in dose-volume calculations (4% v. 10%, p = 0.001). Four factors were positively associated with the occurrence of a concentration error: fewer infusions prepared in the previous week (p = 0.007), increased number of years of professional experience (p = 0.01), the use of the more concentrated stock solution (p < 0.001) and the preparation of smaller dose volumes (p < 0.001). Larger magnitude errors were associated with fewer hours of sleep in the previous 24 hours (p = 0.02), the use of more concentrated solutions (p < 0.001) and preparation of smaller infusion doses (p < 0.001).

Interpretation: Our data suggest that the reduction of provider fatigue and production of pediatric-strength solutions or industry-prepared infusions may reduce medication errors.

Figure 1: Steps involved in infusion preparation and corresponding tasks required of participants The first 2 steps (medication order and vial concentration) were predetermined as part of the study design. Errors were evaluated in the 5 other tasks. *An error was identified if the result of the task or the concentration of the prepared infusion deviated by 10% or more from the expected value; a volumetric error was defined as a deviation of 5% or more from the expected volume; in addition, absolute log-transformed errors were calculated from the worst concentration measured versus the ideal (ordered) concentration.