Reminding staff of diligence during the medication process is not enough to ensure safety: Learning from wrong fluid product selection incidents in the care of critically ill patients.

Background and objectives: Wrong fluid product selection may cause harm to patients. This study aimed to describe voluntarily reported wrong fluid product selection incidents, including their consequences, the reported latent conditions and active failures leading to these and the suggested safeguards to prevent their occurrence, and to compare the suggested and literature-based safeguards to improve the fluid therapy safety within the intensive care (ICU) environment. Methods: All voluntarily and anonymously reported wrong fluid product selection incidents in all Finnish ICUs during 2007-2017 were reviewed. The incident reports included categorized data that were analyzed quantitatively, and narratives that were analyzed qualitatively, using content analysis. The results were reported as frequencies and percentages and described by using Reason's model of human error. Results: Over the eleven years, one wrong fluid product selection incident was reported every six days ( Conclusions: Wrong fluid product selection incidents with various latent conditions and active failures were reported more than once a week. To minimize the serious