Iatrogenic intravenous medication errors reported to the PIC Erfurt

Abstract

Background. We investigated the iatrogenic intravenous medication errors (IIME) reported to the Poisons Information Center (PIC) Erfurt. Methods: All IIME over a ten year period were analyzed retrospectively and categorized into error types, age groups, drugs involved, and estimated risk of toxicity. Results. From 1997 to 2006 the PIC Erfurt registered 132 cases of IIME. They increased from 7 in 1997 to 31 in 2006. Children accounted for 31.1% of the patients affected and adults for 68.9%. The drug classes (ATC classification) involved most frequently were antipsychotics (9.8%) and antihistamines for systemic use (7.5%). The main types of IIME were overdose (53.1%) and incorrect route of administration (29.7%). The estimated risk of toxicity was: 14.4% none, 71.2% risk of toxicity, and 14.4% unpredictable risk. Medical treatment was recommended in 82%. The outcome of 104 of the 132 (78.8%) courses was unknown. In the 28 cases followed to a known outcome, 9 (32%) were asymptomatic and 19 (68%) symptomatic with minor (9 cases), moderate (1 case), and severe features (6 cases) but mostly complete recovery. Two IIME resulted in hypoxia–induced brain damage and one in death despite of resuscitation. Conclusion. Approximately 0.1% of all calls registered by the PIC Erfurt from 1997 to 2006 concerned IIME. Thirty-two percent of IIME followed to a known outcome resulted in severe symptoms. These data show that IIME can be harmful.

Keywords:

• Iatrogenic intravenous medication errors
• Potassium chloride
• Sucralfate
• Vancomycin