Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2015 Mar 13;5(3):e005948.
doi: 10.1136/bmjopen-2014-005948.

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study

Richard N Keers  1 , Steven D Williams  2 , Jonathan Cooke  3 , Darren M Ashcroft  1
Affiliations

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study

Richard N Keers et al. BMJ Open. .

Abstract

Objectives: To investigate the underlying causes of intravenous medication administration errors (MAEs) in National Health Service (NHS) hospitals.

Setting: Two NHS teaching hospitals in the North West of England.

Participants: Twenty nurses working in a range of inpatient clinical environments were identified and recruited using purposive sampling at each study site.

Primary outcome measures: Semistructured interviews were conducted with nurse participants using the critical incident technique, where they were asked to discuss perceived causes of intravenous MAEs that they had been directly involved with. Transcribed interviews were analysed using the Framework approach and emerging themes were categorised according to Reason's model of accident causation.

Results: In total, 21 intravenous MAEs were discussed containing 23 individual active failures which included slips and lapses (n=11), mistakes (n=8) and deliberate violations of policy (n=4). Each active failure was associated with a range of error and violation provoking conditions. The working environment was implicated when nurses lacked healthcare team support and/or were exposed to a perceived increased workload during ward rounds, shift changes or emergencies. Nurses frequently reported that the quality of intravenous dose-checking activities was compromised due to high perceived workload and working relationships. Nurses described using approaches such as subconscious functioning and prioritising to manage their duties, which at times contributed to errors.

Conclusions: Complex interactions between active and latent failures can lead to intravenous MAEs in hospitals. Future interventions may need to be multimodal in design in order to mitigate these risks and reduce the burden of intravenous MAEs.

Keywords: QUALITATIVE RESEARCH.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Reason's model of accident causation as applied to medication administration error research.
See this image and copyright information in PMC

References

    1. Taché SV, Sönnichsen A, Ashcroft DM. Prevalence of adverse drug events in ambulatory care: a systematic review. Ann Pharmacother 2011;45:977–89. 10.1345/aph.1P627 - DOI - PubMed
    1. Kanjanarat P, Winterstein AG, Johns TE et al. . Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 2003;60:1750–9. - PubMed
    1. Carayon P, Wetterneck TB, Cartmill R et al. . Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. BMJ Qual Saf 2014;23:56–65. 10.1136/bmjqs-2013-001828 - DOI - PMC - PubMed
    1. Keers RN, Williams SD, Cooke J et al. . Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Ann Pharmacother 2013;47:237–56. 10.1345/aph.1R147 - DOI - PubMed
    1. McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf 2013;22:278–89. 10.1136/bmjqs-2012-001330 - DOI - PubMed

Publication types

LinkOut - more resources