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Systematic evaluation of errors occurring during the preparation of intravenous medication

From the Department of Critical Care Medicine (Parshuram), the Department of Pharmacy (Seto, Trope), the Center for Safety Research, Child Health Evaluative Sciences Program (Parshuram, To, Seto, Trope, Koren), the Research Institute, The Hospital for Sick Children; the Departments of Paediatrics (Koren), and Health Policy Management and Evaluation (To, Laupacis), University of Toronto; and the Institute for Clinical and Evaluative Sciences (Laupacis), Toronto, Ont.

Correspondence to: Dr. Christopher S. Parshuram, Department of Critical Care Medicine, Hospital for Sick Children, 555 University Ave., Toronto ON M5G 1X8; fax 416 813-7299; christopher.parshuram{at}sickkids.ca

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 occurence 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.

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