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Assistant Professor in Pharmacy
Department of Pharmaceutical Biology
University of Tübingen
The preparation and administration of intravenous (IV) drugs in the hospital is associated with considerable risk. A recent prospective ethnographic study in two hospitals in the UK suggested that half of IV drug doses were erroneous, with errors being potentially harmful in about a third of cases.(1) Common types of errors were bolus doses being given too quickly and mistakes being made when preparing drugs that required multiple steps. Similar high error rates were reported in other studies (see Table 1).(2–5)
In a further study, we used a model of human error to identify the factors contributing to preparation and administration errors in one German and two UK hospitals.(6–7) Nurses’ lack of knowledge on practical aspects of IV drug preparation and administration, complex design of equipment, a lack of perceived risk and poor role models were the main factors. The latter created a cultural context on the wards where guidelines for safe drug administration of bolus doses were deliberately violated. Based on our studies and the literature (for example, recommendations formulated in the “Good practice statement for the preparation of injections in near-patient areas”(8)), the following issues need to be addressed to reduce error rates.
Training in IV drug preparation and administration
Teaching nurses the theoretical as well as practical aspects of IV drug preparation and administration is very important.
Training sessions should cover the following aspects:
Teaching should involve ward-based training sessions, which show the correct techniques to be used and increase awareness of drugs that have a high risk for adverse effects. It is important to review actual practice regularly, to ensure that safety standards are adhered to and to establish a culture of safe drug use.
Multidisciplinary IV teams involving clinical pharmacists
Clinical pharmacists have been identified as the key healthcare professionals to ensure safe drug use.(9) Countries such as the UK have a ward pharmacy system of daily visits to clinical areas. This places the pharmacists in a good position to recognise safety issues and address them in collaboration with doctors and nurses. Pharmacists in other European countries that do not operate a ward pharmacy system should aim to establish ward contacts to get to know the problems involved in IV drug preparation and administration at the ward level.
In some countries, legal barriers exist to form multidisciplinary IV teams. For example, IV drug administration is not recognised as a nursing task in Germany, although, in practice, it is often carried out by nurses. In such countries, a clear legal framework should establish the responsibilities of each healthcare professional.
Centralised preparation of IV drugs
Centralised preparation of IV drugs by the pharmacy department is common in the USA,(10) but not in Europe, apart from specialised areas such as oncology.(11) The evidence for centralised services (outside oncology) is currently weak, and it is unclear whether they are cost-effective or improve the quality of the service.(12–15) An alternative strategy would be to purchase readily prepared IV drugs from pharmaceutical companies. The effect of the changes would have to be assessed carefully. New types of errors could be introduced, such as transmission errors from the ward to the preparation department. Furthermore, nurses who are no longer used to preparing IV drugs may make serious errors if they have to prepare drugs in an emergency.
The manufacturer’s role
Design issues, such as ampoules looking similar, and the complex design of equipment, such as infusion pumps and drug vial presentations, lead to errors. The manufacturer’s role is to supply products with a high safety standard.
For example, novel drug vial presentations should be tested with a view to their safety when in general use. The safety of their use in practice needs to be monitored, and possible changes in design need to be assessed against safety standards.
Learning from errors
Striving towards an organisation that can learn from adverse events is the ultimate way to reduce errors.(16) This requires a cultural change within the healthcare organisation and among healthcare practitioners. One of the important components is an effective system of identifying, recording, reporting and analysing adverse events, including IV drug errors. The information can then be used to reduce risk through changes in practice and in service organisation and delivery.(17)
In conclusion, measures to reduce preparation and administration need a coordinated approach from practitioners, regulators and the pharmaceutical industry.
Finally, prescribers are reminded that drugs should be given parenterally only when no other route is available.