Intravenous medication errors


Intravenous (i.v.) medication errors are twice as likely to cause harm to patients as medications delivered by other routes of administration (such as tablets or liquids), according to research commissioned by the American Society of Health-System Pharmacists (ASHP). This week, ASHP and leading healthcare organizations released recommended actions to prevent these potentially life-threatening events.

The recommendations, published in the December 15, 2008, issue of the American Journal of Health-System Pharmacy, are a result of an IV Safety Summit convened this summer by ASHP. The Summits goal was to initiate actions that prevent harm and death from I.V. medication errors.

Because errors can occur anywhere in the I.V. medication-use process and effects can be immediate and serious, healthcare leaders and experts participating in the Summit agreed that the issue of i.v. safety urgently needs to be addressed. They achieved consensus on a core set of best practices that everyone should follow to ensure safe i.v. medication use.

Best practices included standardization of infusion concentrations and dosages; comprehensive standardized procedures for ordering, preparing, and administering i.v. medications; and the use of ready-to-administer doses whenever possible.

Participants identified actions that are needed to support universal adoption of best practices.

Actions recommended to be taken within the next one to three years include:

  • Universally standardizing concentrations of “high-alert” i.v. medications (those most likely to cause harm if an error occurs) for all patients, including highly vulnerable patients, such as elderly, newborns, and those with chronic medical conditions;
  • Streamlining the process to bring ready-to-administer standardized infusion concentrations to market; 
  • Using “intelligent” i.v. pumps (e.g., those with safety features that help prevent unsafe rates and doses);
  • Making the business case for i.v. safety to hospital leadership;
  • Establishing multidisciplinary medication safety committees in hospitals to address the prevention of i.v. medication errors.

Long-term recommendations include:

  • Using standardized, easily readable bar codes to verify i.v. drugs and doses; 
  • Establishing multidisciplinary medication safety training for healthcare professionals; 
  • Providing tools and resources to facilitate adoption of the i.v. safety practices; 
  • Exploring new methods to stimulate error reporting and share lessons learned; and 
  • Developing a framework for future research on i.v. medication safety.

Co-conveners of the Summit, along with ASHP, include the ASHP Research and Education Foundation, the United States Pharmacopeia, the Institute for Safe Medication Practices, the Infusion Nurses Society, the National Patient Safety Foundation, and The Joint Commission.

For more information about the summit and these recommendations, visit

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