Oral medications inadvertently given via the intravenous route
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Shah-Mohammadi, Ali-Reza, author Gaunt, Michael J., author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. Institute for Safe Medication Practices, issuing body. ECRI (Organization), issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, [2013]
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Medication Errors -- prevention & control Medication Errors -- statistics & numerical data Administration, Oral Infusions, Intravenous Injections, Intravenous Patient safety Pharmaceutical Preparations -- administration & dosage Risk Management Syringes Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- The inadvertent intravenous (IV) administration of oral medications, while rarely reported, has contributed to serious patient harm, as seen in event reports submitted to the Pennsylvania Patient Safety Authority and in the clinical literature. Analysts identified 20 reports of inadvertent IV administration of oral medications submitted to the Authority between June 2004 and December 2012. All of the events reached the patient, and 20% (n = 4) resulted in patient harm, including one death. A common contributing factor cited in many of these reports was that the oral drug was administered using a parenteral syringe. While the clinical literature on these errors predominantly addresses the administration phase of the medication-use process, events and decisions that precede administration may play a role. Avoiding these types of errors requires more than one error reduction strategy. Strategies to mitigate such errors may include assessing the current medical devices within the facility to understand key system factors playing a role in this type of medication error; dispensing oral medications in the most ready-to-use forms; communicating patients' inability to swallow capsules or tablets to the pharmacy department; and improving healthcare professionals' awareness of such medication errors.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (pages 85-91)).
- NLM Unique ID:
- 101616995 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101616995