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PS-058 A systematic review of trends, rates and burden of harm associated with intravenous drug preparation errors in healthcare settings
  1. N Hedlund
  1. Baxter Healthcare Corporation, Deerfield, USA


Background Intravenous (IV) admixture preparation errors (IAPEs) are a safety concern but their frequency, risk factors and associated burden of harm are not well understood.

Purpose To systematically review published evidence on the occurrence and associated burden of harm from IAPEs in healthcare settings.

Material and methods Searches were conducted in 4 large electronic databases (January 2005–December 2013). Publications reporting rates of IAPE and error types (wrong drug, wrong dose, wrong concentration, wrong diluent, wrong container, wrong route, contamination, and mislabelling) were reviewed.

Results Of 1,267 studies, 21 met the inclusion criteria, with 8 (38%) of these from Europe. Four studies were in critical care settings; 17 in general wards. Of studies reporting on an IV preparation site, 6 reported use of centralised locations with a biological safety cabinet, 11 reported preparation on the nursing ward, and 1 had an even split between the 2. Error types and reported rates varied substantially, including: wrong diluent used in 0.3% to 49% of doses; wrong dilution volumes used in 1% to 21.3% of doses; labelling errors in 9.3% to 99% of IV preparations; and inappropriate sterile technique in 25% to 100% of observed preparations. Higher IAPE rates were reported for ward-based versus centralised IV preparation. The only reports of zero IAPEs involved either computerised dose calculations or the use of automated equipment. The lack of consistent reporting on the types of error and the scarcity of studies reporting error rates made it difficult to identify trends. Error severity and associated burden of harm were not adequately documented to evaluate the impact on patient care or consequences for healthcare facilities.

Conclusion This systematic review identified few studies reporting data on the frequency or burden of harm of IAPEs. The available evidence reported fewer errors when drugs were prepared in the pharmacy than on nursing wards, and when processes were standardised and automated.

References and/or acknowledgements Diane Nitzki George for assistance with data abstraction.

Conflict of interest

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