J Public Health (2004) 12:132–138 DOI 10.1007/s10389-004-0019-4 ORIGINAL ARTICLE Katja Taxis · Nick Barber Causes of intravenous medication errors—observation of nurses in a German hospital Received: 16 June 2003 / Accepted: 13 October 2003 / Published online: 6 March 2004  Springer-Verlag 2004 Abstract Aim: Errors in the preparation and administra- tion of intravenous (IV) drugs are frequent events. Human error theory has recently been applied to understand the causes of IV drug errors in an ethnographic study in the United Kingdom. We used this approach to explore causes of IV drug errors by nursing staff in a German hospital. Methods: A trained and experienced observer accompanied nurses during IV drug rounds on two wards in one German hospital. Information came from observa- tion and talking informally to staff. Human error theory was used to analyse causes of IV errors. Results: Twenty- two nurses were observed for 13 study days. A total of 74 IV drug errors were identified while observing 161 preparations and 135 administrations. Mistakes were frequently related to the selection of the wrong fluid for drug preparation and the co-administration of potential- ly incompatible infusions. Lack of training in IV drug preparation and administration was the main problem. Furthermore, guidelines were ambiguous and did not contain sufficient information. The transcription of drug orders also contributed to drug errors. Conclusion: The introduction of nurse training and guidelines provided by a multidisciplinary team, including a clinical pharmacist, may reduce the high rate of IV drug errors. These measures should be linked to a review of the legal framework to recognise IV drug administration as a nursing task. Keywords Medication errors · Human error theory · Intravenous therapy Introduction Medication errors related to the preparation and admin- istration of drugs are common events in hospitals (Barber and Dean 1998). In observations of the administration of oral doses on four wards in two German hospitals, up to 5% of errors were identified (Taxis et al. 1999). Higher error rates were associated with the preparation and administration of intravenous drugs. We identified an error rate of 48% observing the preparation and admin- istration of 122 doses on two wards in one German non- university hospital (Taxis and Barber 2004). This includ- ed four potentially severe errors, such as the co-admin- istration of several incompatible drugs through the same administration line or the fast injection of an opioid analgesic. Two other studies carried out in German university teaching hospitals also reported a high inci- dence of IV drug errors (Wirtz et al. 2003; Hoppe-Tichy et al. 2002). Table 1 summarises the main results of these studies. Similar IV drug error rates have been found in UK hospitals (Taxis and Barber 2003a; Wirtz et al. 2003; O’Hare et al. 1995). Investigating the causes of the errors is the first step towards error prevention (Leape 1994). Human error theory is increasingly used as a theoretical base to identify factors contributing to errors in medicine (Leape et al. 1995; Stanhope et al. 1997; Vincent et al. 2000; Dean et al. 2002). The analysis of large-scale accidents in high- risk industries found that the design of systems, pre- existing organisational factors and the conditions, con- ventions and procedures for the use of technology can contribute significantly to disasters. Based on such research, Reason developed the model of organisational accident causation (Reason 2001). He distinguishes be- K. Taxis · N. Barber Department of Practice and Policy, The School of Pharmacy, University of London, 29–39 Brunswick Square, London, WC1N 1AX, UK K. Taxis Pharmazeutische Biologie, Pharmazeutisches Institut, Universität Tübingen, Auf der Morgenstelle 8, 72076 Tübingen, Germany K. Taxis ( ) ) Rijksuniversiteit Groningen, Sociale Farmacie en Farmacotherapie, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands e-mail: katja.taxis@farm.rug.nl Tel.: +31-50-3637576 Fax: +31-50-3632772