Medication Errors in a Nurse-Controlled Parenteral Admixture Program

Abstract

The central purpose of this study was to determine by performance observation, whether nurses do or do not commit errors when they control the preparation and administration of parenteral admixtures. One hundred observations (30.2% of all admixtures prepared in the study hospital during the observation period) were made on medical-surgical nursing units in a private community hospital. Results showed a 21% medication error rate when nurses prepared parenteral admixtures. The observed error rate was significantly higher than in other studies where nurses prepared and administered other types of medications even though in this study an error was defined only as preparation of wrong drug or iv solution, wrong dosage, unordered drugs or preparation of admixtures containing incompatible drugs. Deviations from recommended preparation procedures were also noted but were not included in the overall 21% medication error rate calculations. Using the areas of recommended preparation procedures observed in the study, deviations were noted in 99% of the 100 parenteral admixtures prepared. Causes for the observed medication errors were also determined where practical. Nonadherence to written nursing procedures, transcription errors involving medication cards, number of interruptions during each admixture and nonuse of available information sources were the major factors leading to parenteral admixture medication errors. Conclusions of the study indicate that pharmacists are justified in preparing parenteral admixtures. Suggestions are made for future study of the significance of observed deviations in recommended preparation procedures.