Medication errors in intravenous drug preparation and
administration: a multicentre audit in the UK, Germany and
D H Cousins, B Sabatier, D Begue, C Schmitt, T Hoppe-Tichy
See end of article for
Professor D H Cousins,
Practice Unit, University of
Derby, Mickleover, Derby
DE3 5GX, UK;
Accepted for publication
26 February 2005
Qual Saf Health Care 2005;14:190–195. doi: 10.1136/qshc.2003.006676
Background: Previous studies have identified medication errors in preparing and administering
intravenous medicines of 13–84% in hospitals in individual countries.
Objective: To compare the effect of the design and implementation of systems for the preparation and
administration of intravenous therapy in hospitals in three European countries on the number of observed
medication errors. To gain a better understanding of these risks and the methods used in each country to
Design: Prospective audit.
Setting: Six hospital departments in the UK, Germany and France willing to participate in the audit as part
of a quality improvement programme.
Methods: Direct observation of the preparation and the administration of intravenous drugs made by a
single observer in each country.
Main outcome measures: Medication process errors.
Results: 824 doses were prepared and 798 doses administered. The product was either not labelled or
incorrectly labelled in 43%, 99%, and 20% of doses administered in the UK, German and French hospitals,
respectively. The wrong diluent was used in 1%, 49% and 18% of cases, respectively, and the wrong rate
of administration was selected for 49%, 21% and 5% of doses observed, respectively. At least one
deviation from aseptic technique was observed among 100%, 58%, and 19% of cases in the three
Conclusion: Uncontrolled risks in the intravenous systems studied were observed in all three countries.
Intravenous therapy must be regarded as a high risk activity where the use of risk management procedures
to minimise risk to patients is seen as a high priority by all those involved with these duties. There is a
requirement to develop better national (possibly international) procedures for safe intravenous practice.
deaths and harm following medication errors such as wrong
drug, dose, diluent, and cross contamination errors with
intravenous therapy.1 2There is a growing awareness of the
importance of the design and implementation of systems of
care on the risk of medication errors.3–7Previous studies have
identified errors in preparing and administering intravenous
medicines of 13–84% in hospitals within one country.8–19One
study has compared errors in two countries.20The design of
procedures and implementation of the system for preparing
and administering intravenous medicines was thought likely
to be influenced by national factors such as legislation,
healthcare system requirements, professional standards,
university course curricula, and delivery of education and
training for healthcare staff. The objective of this audit of
intravenous practice in study hospitals in the UK, France and
Germany was to compare the effect of the design and
implementation of their systems for the preparation and
administration of intravenous therapy on the number of
observed medication errors, and to gain a better under-
standing of theses risks and the methods used in each
country to manage them.
ntravenous therapy is a complex process usually requiring
the preparation of the medicine in the clinical areas before
administration to the patient. There have been reports of
The audit was performed in 2001–2002. The study centres
were general medical and surgical wards in four general
hospitals in the UK, located in the Midlands area of England,
three wards within the Heidelberg University Hospital in
Germany (two surgical intensive care wards and one general
surgical ward), and one department within the Ho ˆpital
Europe ´en Georges Pompidou in Paris, France (Department of
Clinical Immunology). Because the study was part of a
quality improvement programme, the selection of centres was
based on willingness to participate without any attempt at
selecting a representative sample. In all these centres,
hospital pharmacists displayed a strong interest in tracking
intravenous medication errors, all had easy access to the
medical departments, and all expressed a willingness both to
conduct an audit of current practices and to have the results
published. Agreement for the audit was obtained from
hospital ethics committees in all hospitals.
Review of hospital intravenous therapy procedures
Before undertaking the observation the observer reviewed the
hospital written intravenous therapy procedures. In UK
hospitals, because of difficulties in developing and maintain-
ing written procedures, hospitals had adopted the use of the
procedures in a nationally published Manual of Clinical Nursing
Procedures.21In the hospitals in Germany and France there
were also difficulties in developing and maintaining written
procedures; some ward areas had developed their own, in
other cases no formal written procedures were available, and
there were no nationally published procedures. In all cases
there was an assumption that the preparation and adminis-
tration of intravenous medicines had been taught during
basic training within medical and nursing schools and this
information was supplemented by written procedures devel-
oped or endorsed by the hospital.
Definition of intravenous medication error
We defined an intravenous drug error as a deviation in the
preparation or administration of a medicine from a doctor’s
prescription, hospital intravenous procedures, or the manu-
facturer’s instructions. The clinical appropriateness of the
prescription and the potential clinical outcomes resulting
from the observed medication error were not recorded.
Medication recorded in this study can therefore be regarded
as process errors—for example, failure to label prepared
products that were not used immediately and deviations of
more than 1 hour from the prescribed administration time
were considered as errors. Conversely, we excluded from our
definition mistakes that were corrected by a member of staff
An audit form based on procedures in the Manual of Clinical
Nursing Procedures21was piloted and tested in the UK and later
adapted to Germany and France. It was designed to record all
actions of the nursing staff from the time the intravenous
drug prescription was received to the time it was delivered to
patients. The following items were observed:
N qualifications of the staff member (no formal identifica-
N whether the right drug was chosen;
N the right diluent (compatibility with drug and volume to
achieve the right concentration);
N whether the preparation was mixed properly;
N the right dose delivered at the right time through the right
N the right infusion rate;
N details of aseptic method used (hands washed, prepara-
tion surface cleaned, vials and additive ports disinfected
with alcohol impregnated swabs, sterile areas not
N correct labelling (identification of patient, drug, dose and
time for administration).
Observational audit method
The observational audit method was preferred over the self-
reporting of medication errors or the questionnaire survey
method as it has been shown to provide the most reliable
data.22–24In each centre, data were collected by a single
observer. The observer was present on the wards and
accompanied and observed the preparation and administra-
tion of intravenous doses each day excluding weekends.
In the UK and in France the observer was a pharmacy
technician. In Germany the observer was a pharmacy student
in practical training. Information about the objective of the
study was shared with all the staff in the UK but the reason
for the audit was disguised from the nursing staff being
observed in the hospitals in France and Germany. The
observer was instructed not to intervene when an error was
detected except if the error could be the cause of a serious
adverse event. In the UK the data collection took between 5
and 6 weeks, with the pharmacy technician being present on
the ward between 07.30 hours and 19.00 hours. In Germany
the observer was present every day between 10.00 hours
and 15.00 hours for 6 weeks. In France the pharmacy
technician was on the ward from 09.00 hours to 16.15 hours
for 3 months. The results of the study were fed back to the
participating nurses. In Germany the results were published
in two German journals.25 26
Observational data were entered into computer software
spreadsheet applications and analysed in each country before
being pooled together to enable international comparisons.
Characteristics of study centres
The main characteristics of the observations performed are
summarised in table 1. A total of 824 doses prepared and 798
doses administered were observed.
In the UK 299 doses were observed being prepared and 273
doses were observed being administered in general wards of
the four hospitals. Not all prepared doses were observed
being administered either because the intravenous route was
no longer available or the patient was off the ward visiting
other departments. One hundred and twenty two nurses
were observed in the study. The average length of time since
registration was 10.8 years and they had been accredited for
IV therapy for 6.4 years.
In Germany a total of 425 observations were recorded, 343
(81%) in the two surgical intensive care units and 82 (19%)
in the general surgical wards. No information about nurses
could be collected because it was too sensitive.
In France 100 doses were observed being prepared and
administered in the department of clinical immunology by
13 registered nurses with an average length of time since
registration of 8.9 years seniority and nine nurse trainees.
Characteristics of observations
UK wardsGerman wards French ward Total
Ward type mix
Accredited for IV therapy (years)
Type of intravenous products prepared
Liquid into syringe
Liquid into bag
Powder into syringe
Powder into bag
Pharmacy or industry prepared
NC, data not collected.
IV drug audit in three European countries 191
Information about the type of intravenous formulations
observed, grouped into five categories, are shown in table 1. A
minority of the observations derived from ready to use
products, whether pharmacy or industry prepared, with 29
(10%) such observations in the UK hospitals and 25 (6%) in
the German wards. Industry prepared ready to use products
were available in only two out of the four hospitals in the UK.
Incomplete labelling, wrong drug, and dose errors
Lack of appropriate labelling was a frequent error (table 2).
Labelling errors accounted for 118 of 273 observations (43%)
in the UK centres, 421 (99%) in the German centre, and 20
(20%) in the French centre. In 55 cases (20%) in the UK
hospitals, doses were administered 10 minutes or later after
they had been prepared and were not labelled at all.
Similarly, in the German wards 171 (40%) of the doses with
incomplete labels were not administered immediately after
they had been prepared.
Wrong diluent errors and wrong rate errors
The most common error was administering the intravenous
doses at the wrong rate, and usually too quickly (table 3).
Errors of administration rate were 132 out of 273 (49%) in
the UK centres, 34 out of 161 observations (21%) in the
German hospital, and 5 out of 100 (5%) in the French centre.
The second most frequent deviation from recommendations
was preparing the intravenous doses with the wrong diluent.
There were two (1%) such cases in the UK wards, 208 (49%)
in the German centre, and 18 (18%) in the French hospital.
Other errors included not mixing products adequately as
recommended (190 out of 240 (79%) observations in German
wards and one (1%) in the French centre); administering the
product too late or too early (49 (18%) cases in UK hospitals,
seven (2%) in the German hospital) and four (4%) in the
French centre); preparing or infusing the wrong volume (13
(2%) cases overall in all centres); and using the wrong route
of administration (eight (1%) cases overall). In the UK and in
Germany no adverse events related to individual medication
errors were reported. Errors relating to dosage were the
possible cause for four adverse events (4%) in the French
hospital, possibly prolonging hospital stay in three cases.
Aseptic methods for preparing intravenous medicines are
described in table 4. General recommendations include
cleaning the preparation area, washing hands or wearing
sterile gloves, disinfecting vials, ampoules and additive ports
with alcohol impregnated swabs, and making sure that
windows are closed in the preparation area. These recom-
mendations were part of the hospital intravenous therapy
policy in all centres. The preparation area was never cleaned
in the UK hospitals (0%), it was properly cleaned in 18 (4%)
cases in the German wards and in 81 cases (81%) in the
French centre. Hands were never washed (0%) in any of the
four hospitals in the UK nor were sterile gloves worn, but
non-sterile gloves were worn in one hospital in order to
protect nurses from the medicines. Hands were washed in the
German hospital in 22 cases (5%) and 91 preparations (91%)
observed in the French hospital. In the UK centres the tops of
vials were wiped with alcohol impregnated swabs in four
cases (1%). In the German wards not all nurses considered it
important to disinfect the vials, so that it was performed in
only 180 (42%) of cases. Vial tops were swabbed in the
French hospital in 96 (96%) of cases. In the preparation area
either windows were closed or there were no windows at all
in the majority of cases (557 of 724 observations (68%)
overall in the UK and German centres).
This study shows that current systems for intravenous
therapy in the European hospitals studied do not minimise
patient safety risks. Initiatives in individual hospitals or
countries for one or two aspects of the process have reduced
the risk, but overall all systems need to be improved.
Limitations of study
The limitations of our study are as follows:
N Self-selection of hospitals in individual countries to take
part in the audit.
N Convenience sampling of clinical areas within each
Number (%) of labelling errors
Any labelling error
Name of drug missing
Name of patient missing
Time of preparation missing
Label absent or incomplete and
dose not administered immediately
55 (20%) NC
NC, data not collected.
Number (%) of observed medication errors
Product not mixed
Wrong dose or wrong
Wrong administration rate
1 (1%)7 (2%) 5 (5%)
NC, data not collected.
192 Cousins, Sabatier, Begue, et al
N Use of different observers in different countries. It was not
possible to use the same observer(s) for all three countries
and, although we tried to control this variable by agreeing
the definition for medication error and using a standar-
dised audit form, we did not attempt to assess observer
reliability between the three countries.
N The failure to capture some data sets in some countries.
N Focus on process errors. Our method did not attempt to
link the observed process errors to potential clinical
outcomes. Some previous studies13 27have established that
some process errors may be associated with potentially
severe clinical outcomes.
In all three countries difficulties were encountered by
hospitals in developing and maintaining intravenous proce-
dures. Without agreed procedures of this type it is very
difficult to teach, maintain, and audit safe practice. The
intravenous procedures in the Manual of Clinical Nursing
Procedures21in the UK has recently been supplemented by a
publication by the Royal College of Nursing (Standards for
Infusion Therapy published in 2003).28The use of national (and
professionally endorsed) procedures of this type is seen as
very helpful in defining safe practice. However, individual
institutions have a responsibility to audit the implementation
of these procedures regularly and to provide feedback to
practitioners on those areas of practice that are out of
compliance with the procedure.
Wrong drug and dose errors
The results from the UK and German hospitals indicate that a
significant percentage of products that are not labelled are
not used immediately and are stored temporarily in the
clinical area before administration. The temporary storage of
unlabelled intravenous bolus medicines before administra-
tion has not been identified in previous research. We believe
that this is an important risk that may cause the wrong drug
or dose of a medicine to be administered. Practitioners
intending to administer these products may be confused over
the identity of the medicine, dose, or the intended patient to
receive this medicine.
Reviewing written intravenous therapy procedures used in
the study hospital indicates that these procedures provide no
safe practice guidance on this issue. For example, in the
Manual of Clinical Nursing Procedures in the UK,21guidance
is provided on labelling infusion fluids that are to be
administered over several hours, but no recognition is given
to the practice of preparing and temporarily storing intrave-
nous medicines before bolus administration. There is an
opportunity for hospital intravenous therapy procedures and
training programmes to be strengthened by including the
requirement to label medicines that are left unattended, even
for short periods. In anaesthetic practice where intravenous
bolus doses are administered from a range of syringes as an
integral part of the anaesthetic process, a standard for syringe
labelling in critical care areas has recently been introduced in
There are also opportunities for the pharmaceutical
industry to provide design solutions to assist practitioners
to maintain and track product identity in clinical use. These
designs include the use of ready to use pre-filled syringes and
infusions, diluent products that can be permanently con-
nected to drug vials during administration, ampoules and
vials with flag labels; these labels can be transferred to easily
label syringes and infusion bags.
Wrong diluent errors
In the German and French hospitals the most frequent error
was preparing the medicine with the wrong diluent. The use
of the wrong diluent may cause a reduction in the solubility
of the medicine powder being reconstituted that can lead to
powder particulates being administered to the patient. The
use of the wrong diluent can also lead to a reduction in the
stability and activity of the medicine and possible drug
precipitation. The prescription for intravenous medicines
seldom provides information concerning the diluent to be
used to reconstitute or dilute the active intravenous
medicine. The hospital intravenous therapy procedures
indicate that healthcare staff preparing individual intrave-
nous medicines in clinical areas should consult the manu-
facturer’s product literature to obtain this information. Time
constraints, custom and practice, and difficulties finding the
relevant information within product literature are reasons
frequently cited by practitioners why product information is
seldom reviewed. Providing clinical staff with more readily
available information concerning diluents may help to reduce
the use of the wrong diluent. The clinical importance and use
of this information can be reinforced as part of intravenous
therapy training. This information could be added by the
manufacturer or hospital pharmacy department as an
additional warning label in large text to the outside of the
medicine packaging. Quick reference tables could also be
produced for individual hospitals or wards and displayed on
the outside of ward medicine cupboards for easy access.
Diluent products can also be supplied with medicines to
provide a design solution to the problem. Pharmaceutical
industry and/or hospital pharmacy departments could pack-
age these products together to assist practitioners to use the
correct diluent with the medicine. Another alternative
strategy is, where possible, to provide the intravenous
product ready diluted and ready to administer to avoid
diluent selection errors.
Wrong rate errors
In the UK hospitals the most frequent intravenous medica-
tion errors were related to the administration rate, usually
higher than is recommended by manufacturers—for exam-
ple, a 10 ml dose of antibiotics administered by hand in a
syringe in less than 1 minute instead of the 3–5 minutes
recommended in the Specification of Product Characteristics
(SPC), a result that is consistent with previous find-
ings.9 10 12 26Whatever the administered drug characteristics,
fast rates of drug administration are associated with pain,
phlebitis, and loss of cannula patency.30It could be observed
that such errors were less frequent in the two hospitals
Aseptic methods of preparation: values are numbers (percentages)
Cleaned preparation area
Swab vial top
Window closed in preparation area
NC, data not collected.
IV drug audit in three European countries 193
equipped with CIVA and in the three hospitals that could
provide industry prepared ready to use products. These types
of products are presented in larger volumes to be infused by
slow intravenous infusion. Once again, information concern-
ing the rate of administration of intravenous bolus injections
is seldom included in prescription details, and this informa-
tion is not included in hospital intravenous therapy
procedures. Practitioners are again expected to locate this
information among the small print details in manufacturers’
product information. Providing clinical staff with more
readily available information concerning the safe rate of
administration on medicine packaging or the use of quick
reference tables may help to improve practice. Taxis and
Barber in 2003 observed that, in some instances, the safe
speed of injection of bolus doses was being deliberately
violated because of lack of perceived risk, poor role models,
and available technology.19
However, it may be argued that practitioners have
insufficient time to administer intravenous bolus injections
safely even when they are reminded of the correct admin-
istration rate. This observation is supported in the UK by the
high percentage of wrong time errors (defined as adminis-
tration of intravenous medicines 1 hour or more from the
prescribed time). As this may indicate a high work load,
wrong time errors are likely to be increased if nursing staff
have to administer each bolus dose over 3–5 minutes as
recommended in the product literature. If this is the case,
then alternative methods of intravenous administration
should be used such as short intravenous infusion therapy
that does not require the practitioner to be at the bedside
during the administration of the medicine.
Review of the written intravenous therapy procedures in the
study hospitals revealed that aseptic requirements included
hand washing before the procedure and cleaning ampoules,
vials and intravenous infusion closures. These process errors
associated with poor aseptic technique were the result of
failure of the implementation of procedures rather than
the availability or design of the procedures themselves. All
nurses in the study had received training on intravenous
therapy, although not all had received this training recently.
Reason defines ‘‘violations’’ as deliberate—but not necessa-
rily reprehensible—deviations from those practices deemed
necessary by designers, managers, and regulatory agencies
to maintain the safe operation of potentially hazardous sys-
tems. Reason subdivides this classification into routine and
exceptional violation categories. The frequency with which
aseptic process errors were observed in the study hospitals in
the UK and Germany indicate that these were routine
The importance of the safety procedure needs to be
apparent to the operators, and there is little research
demonstrating the importance of infection controls during
the preparation of intravenous medicines in ward areas.
There is a general assumption made by operators that the
intravenous medicines are being prepared for immediate use
and that the risk of infection is small. However, recent
research in a German hospital following the deaths of two
patients from meningitis caused by contamination of contrast
media found other contaminated multiple dose vials in ward
areas, and poor handling and storage of these types of
In the French centre the clinical staff had recently been
updated on aseptic methods and following the diagnosis
of Legionnaire’s disease in nine patients of whom four
eventually died. In this hospital the relevance and surveil-
lance of aseptic safety controls had been re-established.
Nurses in the French hospital were observed to clean the
preparation area (81%), wash hands (91%), and swab vial
tops (96%) while results were much poorer in the UK and in
the German centres with preparation area cleaned in 2% of
cases overall, hands washed in 3% of cases, and vial tops
swabbed in 1% of cases in the UK hospitals and 42% of cases
in the German hospital.
In the UK the National Patient Safety Agency published a
Patient Safety Alert in September 2004 entitled ‘‘Clean Your
Hands’’ that recognised hands as a repository of microbes
which cause infection and the practical difficulties that staff
face cleaning their hands between patients.31The Alert
requires the National Health Service in England and Wales
to install alcohol based hand rubs at points of care by April
2005. These hand rub products are quick to use and can be
applied without interrupting work. This high profile cam-
paign will alert UK healthcare staff to the importance of hand
cleaning and should improve the frequency of hand cleaning
before the preparation of intravenous medicines, but this will
need to be regularly audited.
A training strategy is also required to reinforce the clinical
need to implement the agreed aseptic controls when
preparing intravenous medicines. In the UK hospital phar-
macy technician staff preparing intravenous medicines in
aseptic clean rooms require regular competency assessment
of aseptic technique using a simulation technique with
nutrient broth.32Manipulations take place in the usual work
environment and the products produced are incubated to
determine the contamination rate. Staff who contaminate
products in simulation are withdrawn from duty and are
retrained and undertake additional testing until they are
able to produce uncontaminated products. Although it is
unlikely to be practical to assess the intravenous therapy
aseptic technique of all nursing staff in a hospital, it would
be possible for small numbers to be assessed randomly—
possibly during training sessions—and summary information
concerning the contamination rate to be fed back to all
nursing staff to stress the clinical importance of good aseptic
In conclusion, it has been worthwhile comparing the
systems for intravenous medicine in hospitals in three
European countries. We found uncontrolled risks in the
Intravenous therapy must be regarded as a high risk activity
where the use of risk management procedures to minimise
risk to patients is seen as a high priority by all those involved
in all three countries.
N Prepared intravenous medicines were left for short
periods of time unlabelled before being administered
to patients. This is a previously unidentified risk that
may cause the wrong drug or dose of a medicine to be
administered in error to a patient.
N A frequent error involved using the wrong diluent to
prepare an intravenous medicine. This may cause
difficulties in dissolving drug powders, inactivation,
and possible precipitation of the drug out of solution.
N Intravenous bolus medicines required to be adminis-
tered by hand in a syringe were frequently adminis-
tered too quickly and this practice is associated with
phlebitis and loss of cannula patency.
N Aseptic procedures required for the safe preparation of
intravenous doses were frequently violated by staff who
were not always aware of the clinical consequences of
not following these procedures.
194 Cousins, Sabatier, Begue, et al
with these duties. There is a requirement to develop better Download full-text
national (possibly international) procedures for safe intrave-
nous practice. These procedures can be used to train,
maintain, and audit practice.
D H Cousins, University of Derby, Derby, UK
B Sabatier, D Begue, Ho ˆpital Europe ´en Georges Pompidou, Paris,
C Schmitt, MDS Pharma Services, Se `vres, France
T Hoppe-Tichy, Heidelberg University Hospital, Heidelberg, Germany
Supported by a grant from Baxter Healthcare International.
1 Cousins DH, Upton DR. Medication error report 125: A patient dies following
cross infection with falciparum malaria. Pharmacy in Practice 1999;9:220–2.
2 Cousins DH, Upton DR. Medication error 79: How to prevent IV medicine
errors. Pharmacy in Practice 1997;7:310–1.
3 Reason J. Human error. Cambridge: Cambridge University Press, 1990.
4 Department of Health. An organisation with a memory. London: Department
of Health, 2000.
5 Department of Health. Building a safer NHS for patients. London: Department
of Health, 2001.
6 Department of Health. Building a safer NHS for patients. Improving safe
medication practice. London: Department of Health, 2004.
7 Department of Health. Design for safety. A system-wide design-led approach
to tackling patient safety in the NHS. London: Department of Health, 2003.
8 Thur MP, Miller WA, Latiolais CJ. Medication errors in a nurse controlled
parenteral admixture programme. Am J Hosp Pharm 1972;29:293–304.
9 Clark CM, Bailie GR, Whitaker AM, et al. Parenteral drug delivery: value for
money? Pharm J 1986;236:453–5.
10 Cousins DH, Lee M, Stanaway M, et al. Implementation and evaluation of a
centralised IV additive service for antibiotic injections. Pharm J 1989:HS14–6.
11 O’Hare MCB, Gallagher T, Shields MD. Errors in the administration of
intravenous drugs. BMJ 1995;10:1536–7.
12 Hartley GM, Dhillon S. An observational study of the prescribing and
administration of intravenous drugs in a general hospital. In J Pharm Pract
13 Tissot E, Cornette C, Demoly P, et al. Medication errors at the administration
stage in an intensive care unit. Intensive Care Med 1999;25:353–9.
14 Bruce J, Wong I. Parenteral drug administration errors by nursing staff on an
acute medical admissions ward during day duty. Drug Saf 2001;24:855–62.
15 Belkacem K, Lepaux DJ, Oliger R. Medication error rate in the hospital setting:
a pilot study at the Jury-les-Metz Hospital Center. Presse Med
16 Calabrese AD, Erstad BL, Brandl K, et al. Medication administration errors in
adult patients in the ICU. Intensive Care Med 2001;27:1592–8.
17 Van den Bemt PM, Fijn R, van der Voort PH, et al. Frequency and
determinants of drug administration errors in the intensive care unit. Crit Care
18 Taxis K, Barber N. Ethnographic study of incidence and severity of
intravenous drug errors. BMJ 2003;326:684–8.
19 Taxis K, Barber N. Causes of intravenous medication errors an ethnographic
study. Qual Saf Health Care 2003;12:343–7.
20 Wirtz V, Taxis K, Barber ND. An observational study of intravenous
medication errors in the United Kingdom and in Germany. Pharm World Sci
21 Mallett J, Dougherty L. Manual of clinical nursing procedures, 5th edn.
Oxford: Blackwell Publishing, 2000.
22 Allan EL, Barker KN. Fundamentals of medication errors research. Am J Hosp
23 Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting
medication errors in 36 hospitals and skilled-nursing facilities. Am J Health
Syst Pharm 2002;59:436–46.
24 Dean B, Barber N. Validity and reliability of observational methods for
studying medication administration errors. Am J Health Syst Pharm
25 Hoppe-Tichy T, Noe-Schwenn S, Wahlig A, et al. Medikationsfehler bei der
Applikation parenteraler Arzneimittel. Krankenhauspharmazie
26 Hoppe-Tichy T, Noe-Schwenn S, Wahlig A, et al. Medikationsfehler mit
schlimmen Folgen. Pflege Aktuell 2002;56:469–71.
27 Mattner F, Gastmeir P. Bacterial contamination of multiple-dose vials: a
prevalence study. Am J Infect Control 2004;32:12–6.
28 Royal College of Nursing. Standards for infusion therapy. London, Royal
College of Nursing, 2003 (available at www.rcn.org.uk).
29 Birks RJS. Syringe labelling an international standard. Anaesthesia
30 Backhouse CM, Ball BR, Booth S, et al. Particulate contaminants of intravenous
medication and infusions. J Pharm Pharmacol 1987;39:241–5.
31 National Patient Safety Agency. Patient Safety Alert 04. Clean your hands
campaign can save lives. London, National Patient Safety Agency, 2004
(available at www.npsa.nhs.uk).
32 Beaney AM. Quality assurance of aseptic preparation services, 3rd edn.
London: The Pharmaceutical Press, 2001.
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IV drug audit in three European countries195