Iatrogenic intravenous medication errors reported to the PIC Erfurt

Clin Toxicol (Phila). 2009 Feb;47(2):169-73. doi: 10.1080/15563650701781931.

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.

MeSH terms

  • Adolescent
  • Adult
  • Age Distribution
  • Aged
  • Child
  • Child, Preschool
  • Germany / epidemiology
  • Humans
  • Iatrogenic Disease / epidemiology*
  • Infant
  • Infusions, Intravenous
  • Injections, Intravenous
  • Medication Errors* / statistics & numerical data
  • Middle Aged
  • Poison Control Centers* / statistics & numerical data
  • Poisoning / mortality
  • Poisoning / therapy
  • Retrospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • Time Factors
  • Young Adult