AN OBSERVATIONAL STUDY ON CAUSES OF INTRAVENOUS MEDICATION ERRORSUSING A FRAMEWORK OF HUMAN ERROR THEORY

Binu K.M.*, Pratima K.C., S. Nikhila, Sarfaraz M.D., H. Doddayya and S. Antin

ABSTRACT

Background: Human error theory is increasingly used to study adverse events in medicine, but has not yet been applied to study IV errors in Indian hospitals. The objective of the study was to find out the causes of intravenous preparation and administration errors using a frame work of human error theory. Methods: A prospective study using disguised observation was carried out for six monthsin medical, surgery, paediatrics and ICU wards. Nurses were accompanied daily during IV drug rounds. Details of each IV drug preparation and administration, and the errors identified were recorded on a standard data entry form. Human error theory was used to analyse the causes of IV errors. Results: IV drugs prescribed for 438 patients were observed during study period, of which 231 (52.83%) were females and 207 (47.27%) were male patients. One or more errors were occurred in the preparation of 421 out of 827 drug doses (50.90%).Preparation errors occurred in 110 IV doses (26.44%), administration errors in 311 IV doses (75.66%). Four hundred and twenty one human errors were identified, lack of knowledge of preparation or administration procedures were frequent failures in handling technology. Almost 110(26.12%) errors were identified in designing of technique. It was found that high work load 96(22.8%) also a reason for human error. Conclusion: Human error theory was used to point out intravenous medication errors due to preparation and administration. Our study suggests that experienced and trained personnel’s are required to administer IV medication so errors can be minimized or avoided.

Keywords: Human error theory, IV Medication errors, Nurse, Observational study.