Incidence of Intravenous Medication Errors in a Chinese Hospital

Qian Ding; Kenneth N Barker; Elizabeth A Flynn; Salisa C Westrick; Ming Chang; Robert E Thomas; Kimberly Braxton-Lloyd; Richard Sesek

doi:10.1016/j.vhri.2015.03.004

Incidence of Intravenous Medication Errors in a Chinese Hospital

Value Health Reg Issues. 2015 May:6:33-39. doi: 10.1016/j.vhri.2015.03.004. Epub 2015 May 16.

Authors

Qian Ding¹, Kenneth N Barker², Elizabeth A Flynn³, Salisa C Westrick², Ming Chang⁴, Robert E Thomas⁵, Kimberly Braxton-Lloyd⁶, Richard Sesek⁶

Affiliations

¹ Department of Pharmaceutical Sciences, Ferris State University, Big Rapids, MI, USA. Electronic address: qianding@ferris.edu.
² Department of Health Outcomes Research and Policy, Auburn University, Auburn, AL, USA.
³ Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
⁴ China Resources Purenhong Pharmaceutical Co., Ltd., Beijing, China.
⁵ Department of Industrial and Systems Engineering, Auburn University, Auburn, AL, USA.
⁶ Department of Pharmacy Practice, Auburn University, Auburn, AL, USA.

PMID: 29698190
DOI: 10.1016/j.vhri.2015.03.004

Abstract

Objectives: The purpose of this study was to explore intravenous (IV) medication errors in a Chinese hospital. The specific objectives were to 1) explore and measure the frequency of IV medication errors by direct observation and identify clues to their causes in Chinese hospital inpatient wards and 2) identify the clinical importance of the errors and find the potential risks in the preparation and administration processes of IV medications.

Methods: A prospective study was conducted by using the direct observational method to describe IV medication errors on two general surgery patient wards in a large teaching hospital in Beijing, China. A trained observer accompanied nurses during IV preparation rounds to detect medication errors. The difference in mean error rates between total parenteral nutrition (TPN) and non-TPN medications was tested by using the Mann-Whitney U test.

Results: A final total of 589 ordered IV doses plus 4 unordered IV doses as prepared and administered to the patients was observed from August 3, 2010, to August 13, 2010. The overall error rate detected on the study ward was 12.8%. The most frequent errors by category were wrong dose (5.4%), wrong time (3.7%), omission (2.7%), unordered dose (0.7%), and extra dose (0.3%). Excluding wrong time errors, the error rate was 9.1%. Non-TPN medications had significantly higher error rates than did TPN medications including wrong time errors (P = 0.0162).

Conclusions: A typical inpatient in a Chinese hospital was subject to about one IV error every day. Pharmacists had a very limited role in ensuring the accuracy of IV medication preparation and administration processes.

Keywords: direct observation; high-alert medications; intravenous; medication errors.