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Ethnographic study of incidence and severity of intravenous drug errors

BMJ 2003; 326 doi: (Published 29 March 2003) Cite this as: BMJ 2003;326:684
  1. Katja Taxis (katja.taxis{at}, assistant professor in pharmacy,
  2. Nick Barber, professor of the practice of pharmacy
  1. Department of Practice and Policy, School of Pharmacy, University of London, London WC1 1AX
  1. Correspondence to: K Taxis, Pharmazeutische Biologie, Pharmazeutisches Institut, Universität Tübingen, Auf der Morgenstelle 8, 72076 Tübingen, Germany
  • Accepted 30 January 2003


Objectives: To determine the incidence and clinical importance of errors in the preparation and administration of intravenous drugs and the stages of the process in which errors occur.

Design: Prospective ethnographic study using disguised observation.

Participants: Nurses who prepared and administered intravenous drugs.

Setting: 10 wards in a teaching and non-teaching hospital in the United Kingdom.

Main outcome measures: Number, type, and clinical importance of errors.

Results: 249 errors were identified. At least one error occurred in 212 out of 430 intravenous drug doses (49%, 95% confidence interval 45% to 54%). Three doses (1%) had potentially severe errors, 126 (29%) potentially moderate errors, and 83 (19%) potentially minor errors. Most errors occurred when giving bolus doses or making up drugs that required multiple step preparation.

Conclusions: The rate of intravenous drug errors was high. Although most errors would cause only short term adverse effects, a few could have been serious. A combination of reducing the amount of preparation on the ward, training, and technology to administer slow bolus doses would probably have the greatest effect on error rates.

What is already known on this topic

What is already known on this topic Errors in preparing and administering intravenous drugs can cause considerable harm to patients

Reduction of drug errors is a government health target in the United Kingdom and the United States

What this study adds

What this study adds Errors occurred in about half of the intravenous drug doses observed

Errors were potentially harmful in about a third of cases

The most common errors were giving bolus doses too quickly and mistakes in preparing drugs that required multiple steps


  • Funding School of Pharmacy, University of London. The guarantors accept full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Competing interests None declared.

    Ethical approval: The ethics committees of the participating hospitals approved the study.

  • Accepted 30 January 2003
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