IV preparation errors
Abstract:
Background: Intravenous admixture preparation errors (IAPEs) may lead to patient harm. Insight into the prevalence as well as the determinants associated with these IAPEs is needed to elicit preventive measures.
Aim: The primary aim of this study was to assess the prevalence of IAPEs. Secondary aims were to identify the type, severity, and determinants of IAPEs.
Method: A prospective observational study was performed in a Dutch university hospital. IAPE data were collected by disguised observation. The primary outcome was the proportion of admixtures with one or more IAPEs. Descriptive statistics were used for the prevalence, type, and severity of IAPEs. Mixed-effects logistic regression analyses were used to estimate the determinants of IAPEs.
Results: A total of 533 IAPEs occurred in 367 of 614 admixtures (59.8%) prepared by nursing staff. The most prevalent errors were wrong preparation technique (n = 257) and wrong volume of infusion fluid (n = 107). Fifty-nine IAPEs (11.1%) were potentially harmful. The following variables were associated with IAPEs: multistep versus single-step preparations (adjusted odds ratio [ORadj] 4.08, 95% confidence interval [CI] 2.27-7.35); interruption versus no interruption (ORadj 2.32, CI 1.13-4.74); weekend versus weekdays (ORadj 2.12, CI 1.14-3.95); time window 2 p.m.-6 p.m. versus 7 a.m.-10 a.m. (ORadj 3.38, CI 1.60-7.15); and paediatric versus adult wards (ORadj 0.14, CI 0.06-0.37).
Conclusion IAPEs, including harmful IAPEs, occurred frequently. The determinants associated with IAPEs point to factors associated with preparation complexity and working conditions. Strategies to reduce the occurrence of IAPEs and therefore patient harm should target the identified determinants.
Reference:
Jessurun JG, Hunfeld NGM, van Rosmalen J, van Dijk M, van den Bemt PMLA. Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital. Int J Clin Pharm. 2021 Aug 7. doi: 10.1007/s11096-021-01310-6. Epub ahead of print. PMID: 34363192.