Accidental IV administration of epinephrine instead of midazolam at colonoscopy

Peer review under responsibility of Alexandria University Faculty of Medicine.

The manuscript was previously presented as a poster in the 14th International Congress of the Egyptian Society of Hepatology, Gastroenterology and Infectious Diseases in Alexandria. Poster Session, August 30, 2012.

Available online 4 December 2014

Figures & data

Figure 1 Epinephrine ampoule and midazolam ampoule.

Table 1 Causes of medication administration errors.

Causes	Examples
Unsafe acts
Slips and lapses	Misidentification of medication or a patient. Misreading a medication label, prescription or other documentation. Selection of a wrong medication. Failure to administer a drug. Carelessness
Knowledge- and rule-based mistakes	Inadequate knowledge of medication
Violations	Situational violation (those arising due to necessity e.g. poorly designed protocols or lack of staff). Violation limited predominantly to data collection method (conversation with subjects to determine error causality)
Other unsafe acts	Calculation errors. Faulty checking activities. Not following instructions
Local workplace factors
Patient factors	Availability (absent/sleeping patients during drug administration rounds). Acuity (wrong time or dose omission due to severity of patient illness). Patient behavior (non-cooperation)
Policies and procedures	Failure in following policy/procedures. Absence of a policy. Over-laborious or generally unsuitable policies. Inadequate procedures
Ward based equipment	Access (insufficient equipment used to aid drug administration e.g., gloves. Lack of access or misplacement of drug charts). Functionality (un-calibrated or malfunctioning equipment e.g., infusion pumps. Ambiguous equipment design e.g., syringe driver or drug packaging)
Staff health status and personality	Physical feelings of fatigue, tiredness/sleep deprivation, sickness and general discomfort. Physical exhaustion due to long hours and lack of breaks/food. Mental state (stress, boredom, nervousness [with being busy and young] and poor mood). Personality (lack of assertiveness/confidence, error perception and conscientiousness)
Training and experience	Insufficient experience (unfamiliar with the medication, environment, procedures or equipment). Inadequate training (the practicalities of preparing and administering medication, inappropriate assessment of intravenous drug administration skills)
Communication	Poor communication. Difficulty with written communication (illegible and unclear/messy prescriptions). Inadequate written communication (prescriptions, documentation, transcription). Problems with labeling
Supervision and social dynamics	Poor supervision by senior colleagues. Apparent overconfidence in/from other nurses when carrying out independent checks. Pressure from other staff members. Confronting and intimidating behavior. Social isolation from colleagues
Interruptions and distractions	Interruptions (conversations, phone calls and patient acuity). Distractions (ward rounds or face-to-face/telephone conversations with co-workers/patients)
Workload and skill mix	Heavy staff workload (end of shift/patient transfer pressures, patient load and multitasking). Skill mix (a lack of qualified staff, working with inexperienced or new staff members and short staffing)
General work environment	Unsuitable environment (noise, lighting, emergencies and busy or chaotic working environments)
Medicines supply and storage	Medication unavailability (lack of ward stock, misplaced medication or lost on the ward). Pharmacy department problems (delayed deliveries, incorrect dispensing and unavailable stock)
Local working culture	Bad practices (administering medicines without a prescription). Exhaustion (due to working double shifts or not taking breaks). Levels of trust between colleagues
Organizational decisions
High level/strategic decisions	Lack of hospital policy. Misguided policy (low nurse staffing). Poor respond of supervisory teams to errors