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International Journal of Clinical Pharmacy
Published in: International Journal of Clinical Pharmacy 1/2022

Open Access 01-02-2022 | Research Article

Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Authors: Janique G. Jessurun, Nicole G. M. Hunfeld, Joost van Rosmalen, Monique van Dijk, Patricia M. L. A. van den Bemt

Published in: International Journal of Clinical Pharmacy | Issue 1/2022

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Abstract

Background Intravenous admixture preparation errors (IAPEs) may lead to patient harm. Insight into the prevalence as well as the determinants associated with these IAPEs is needed to elicit preventive measures. Aim The primary aim of this study was to assess the prevalence of IAPEs. Secondary aims were to identify the type, severity, and determinants of IAPEs. Method A prospective observational study was performed in a Dutch university hospital. IAPE data were collected by disguised observation. The primary outcome was the proportion of admixtures with one or more IAPEs. Descriptive statistics were used for the prevalence, type, and severity of IAPEs. Mixed-effects logistic regression analyses were used to estimate the determinants of IAPEs. Results A total of 533 IAPEs occurred in 367 of 614 admixtures (59.8%) prepared by nursing staff. The most prevalent errors were wrong preparation technique (n = 257) and wrong volume of infusion fluid (n = 107). Fifty-nine IAPEs (11.1%) were potentially harmful. The following variables were associated with IAPEs: multistep versus single-step preparations (adjusted odds ratio [ORadj] 4.08, 95% confidence interval [CI] 2.27–7.35); interruption versus no interruption (ORadj 2.32, CI 1.13–4.74); weekend versus weekdays (ORadj 2.12, CI 1.14–3.95); time window 2 p.m.-6 p.m. versus 7 a.m.-10 a.m. (ORadj 3.38, CI 1.60–7.15); and paediatric versus adult wards (ORadj 0.14, CI 0.06–0.37). Conclusion IAPEs, including harmful IAPEs, occurred frequently. The determinants associated with IAPEs point to factors associated with preparation complexity and working conditions. Strategies to reduce the occurrence of IAPEs and therefore patient harm should target the identified determinants.
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Metadata
Title
Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital
Authors
Janique G. Jessurun
Nicole G. M. Hunfeld
Joost van Rosmalen
Monique van Dijk
Patricia M. L. A. van den Bemt
Publication date
01-02-2022
Publisher
Springer International Publishing
Published in
International Journal of Clinical Pharmacy / Issue 1/2022
Print ISSN: 2210-7703
Electronic ISSN: 2210-7711
DOI
https://doi.org/10.1007/s11096-021-01310-6

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