Incidence and severity of intravenous drug errors in a German hospital.

OBJECTIVE: To determine the incidence of errors in preparing and administering intravenous (i.v.) drugs, identify the stages in the process at which errors occurred and evaluate their clinical importance.
METHODS: A prospective ethnographic study using disguised observation was carried out on two wards in one German non-university hospital.
RESULTS: We observed 22 nurses administering 122 i.v. drug preparations and administrations. One or more errors occurred in the preparation and administration of 58 of 122 i.v. drug doses (error rate 48%, 95% confidence interval 39-57%). In total, 65 errors were identified. Of doses, 4 had potentially severe errors (3%), 38 (31%) potentially moderate errors and 16 (13%) potentially minor errors. Common errors included multiple step preparations and the co-administration of potentially incompatible drugs as intermittent infusions.
CONCLUSION: A high incidence of i.v. drug errors was found in the study hospital. Effective strategies to reduce potentially harmful errors are urgently needed. Measures could include a reduction in the number of ward-based i.v. drug preparations, improvement of staff training and the introduction of ward-based clinical pharmacy services.