This Patient Safety Alert highlights a number of risks in prescribing, preparing and administering injectable medicines and makes recommendations for safer use. It is supported by materials to aid implementation and embed safer practice.
The National Reporting and Learning Service received around 800 reports a month relating to injectable medicines between January 2005 and June 2006. The majority resulted in no or low harm to patients, but there were 25 fatal incidents and 28 of serious harm.
Research evidence also indicates that the incidence of errors in prescribing, preparing and administering injectable medicines is higher than for other forms of medicine. In one study, at least one error occurred in 49 per cent of intravenous medicine doses prepared and administered on hospital wards; one per cent of errors were potentially severe; and 29 per cent potentially moderate errors.
Action for healthcare organisations include:
- Risk assessing injectable medicine procedures and products in all clinical areas. Developing an action plan to minimise high risks.
- Ensuring up-to-date protocols and procedures exist for prescribing, preparing and administering injectable medicines.
- Ensuring that essential technical information on injectable medicines is available and accessible at the point of use.
- Implementing a ‘purchasing for safety’ policy to promote procurement of injectable medicines with inherent safety features.
- Training and supervising staff.
- Auditing medication practice with injectable medicines as part of the annual medicines management audit programme.