Evidence map›Paper›PMID 14532365›Full record

ArticleQuality & safety in health care2003

Causes of intravenous medication errors: an ethnographic study.

K Taxis, N Barber

Abstract read
PubMed Full text at PMC Publisher
In one paragraph

Article in Quality & safety in health care, 2003. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 50 papers, 4 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
50citing papers in PubMed, 4 pooled it
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1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

50 citing papers in PubMed, 4 syntheses or guidelines pooled it.

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  20. Stakeholder perceptions of smart infusion pumps and drug library updates: A multisite, interdisciplinary study.American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists · 2019
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4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

2 authors.

K TaxisDepartment of Practice and Policy, The School of Pharmacy, University of London, London WC1N 1AX, UK. katja.taxis@uni-tuebingen.de
N Barber

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundIntravenous (IV) medication errors are frequent events. They are associated with considerable harm, but little is known about their causes. Human error theory is increasingly used to understand adverse events in medicine, but has not yet been applied to study IV errors. Our aim was to investigate causes of errors in IV drug preparation and administration using a framework of human error theory.

methodsA trained and experienced observer accompanied nurses during IV drug rounds on 10 wards in two hospitals (one university teaching hospital and one non-teaching hospital) in the UK. Information came from observation and talking informally to staff. Human error theory was used to analyse the causes of IV error.

results265 IV drug errors were identified during observation of 483 drug preparations and 447 administrations. The most common type of error was the deliberate violation of guidelines when injecting bolus doses faster than the recommended speed of 3-5 minutes. Causes included a lack of perceived risk, poor role models, and available technology. Mistakes occurred when drug preparation or administration involved uncommon procedures such as the preparation of very small volumes or the use of unusual drug vial presentations. Causes included a lack of knowledge of preparation or administration procedures and complex design of equipment. Underlying problems were the cultural context allowing unsafe drug use, the failure to teach practical aspects of drug handling, and design failures.

conclusionsTraining needs and design issues should be addressed to reduce the rate of IV drug preparation and administration errors. This needs a coordinated approach from practitioners, regulators, and the pharmaceutical industry.

Indexed as

Medication ErrorsAnthropology, CulturalCausalityHospitals, PublicHumansInfusions, IntravenousPrimary Health CareUnited Kingdom

Identifiers

PMID14532365
PMCPMC1743768

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.