Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Janique G Jessurun,Patricia M L A Van Den Bemt,Joost Van Rosmalen,Nicole G M Hunfeld,Monique Van Dijk

doi:10.1007/s11096-021-01310-6

Janique G Jessurun, Patricia M L A Van Den Bemt + Show 3 more

Open Access

https://doi.org/10.1007/s11096-021-01310-6

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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.

Highlights

Medication errors occur frequently and are associated with increased patient morbidity and mortality [1,2,3,4,5]
This study showed that Intravenous admixture preparation errors (IAPEs), including potentially harmful IAPEs, are common in clinical practice, which merits implementation of effective systemic defences to improve patient safety
This study showed that IAPEs, including potentially harmful IAPEs, are prevalent in a hospital setting

Summary

Introduction

Medication errors occur frequently and are associated with increased patient morbidity and mortality [1,2,3,4,5]. Intravenous drug therapy, including preparation of intravenous admixtures, poses an increased risk of medication errors and patient harm [3, 6, 7]. Systematic reviews showed that the rates of intravenous admixture preparation errors (IAPEs) varied substantially across studies, but high rates were quite common [4, 7,8,9]. Intravenous admixture preparation errors (IAPEs) may lead to patient harm. 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. Strategies to reduce the occurrence of IAPEs and patient harm should target the identified determinants

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