Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study

BMJ Open
Richard N KeersDarren M Ashcroft

Abstract

To investigate the underlying causes of intravenous medication administration errors (MAEs) in National Health Service (NHS) hospitals. Two NHS teaching hospitals in the North West of England. Twenty nurses working in a range of inpatient clinical environments were identified and recruited using purposive sampling at each study site. Semistructured interviews were conducted with nurse participants using the critical incident technique, where they were asked to discuss perceived causes of intravenous MAEs that they had been directly involved with. Transcribed interviews were analysed using the Framework approach and emerging themes were categorised according to Reason's model of accident causation. In total, 21 intravenous MAEs were discussed containing 23 individual active failures which included slips and lapses (n=11), mistakes (n=8) and deliberate violations of policy (n=4). Each active failure was associated with a range of error and violation provoking conditions. The working environment was implicated when nurses lacked healthcare team support and/or were exposed to a perceived increased workload during ward rounds, shift changes or emergencies. Nurses frequently reported that the quality of intravenous dose-checking acti...Continue Reading

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