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Medication error

Minimising Risk 

"A medication error is any event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use."1 

One in 20 perioperative medication administrations includes a medication error and/or adverse drug event.2 

Causes of medication error and resulting medication incident types. 10-15

 Wrong doseWrong patientWrong drugWrong routeWrong timeWrong flowrateOmitted doseSide effectsInfections
Wrong transcriptionxxxxxxx  
Incorrect labelingxxxxxxx  
Wrong calculationx   xx x 
Difficult preparation technologiesx        
Incomplete container deliveryx        
Adsorption (container/TV sets)x        
Incorrect flow ratex      x 
Insufficiant mixing ingredientsx        
Use of inappropriate diluentsx      x 
Contamination of solutionsx      xx
Wrong storagex       x
Wrong/omitted/passed expiry datex       x

Interruption of nurses during the drug preparation process increases the risk for medication errors17.

In England medication errors are associated with 

  • Costs of GBP

    = 0

    per year

  • Occupation of

    = 0

    bed-days per year

  • Deaths

    = 0

     per year 19

Costs per medication error can reach 111,727 EUR23

 Examples to prevent medication error

Product Measure

Product Measure

Standard concentrations pre-prepared by pharmacy or industry24,25,26,27 

Product Measure

Product Measure

Label/Color Code Concept28,29 and a Barcode/Data Matrix to handle preparation data and close the loop to patient30

Product Measure

Product Measure

 IV pumps with intuitive handling and integrated drug database36,31,32 additionally, compatibility databases33 

Organizational Measures

Organizational Measures

Comprehensive and interprofessional education and training of all involved staff 29,30,36,34,35 as well as ward-based clinical pharmacists36,37

Organizational Measures

Organizational Measures

Organizational Measures: Different storage areas for important drugs (e.g. concentrated potassium chloride)38 and introduction of separate medication preparation rooms on ward39

Organizational Measures

Organizational Measures

Incident reporting system36,42,40 

Moreover, it must be the aim of every employee in the health care sector, to ensure the 9 “Rights“.41, 42 

9 Rights of Effective Prevention
Right patientRight timeRight action
Right drugRight doseRight form
Right routeRight documentationRight response

Current guidelines an recommendations

More products

For more products, please check the B. Braun Product Catalogue

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Scientific Evidence 


[1] National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors. Available from: (accessed 20 Dec, 2022) 

[2] Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2016 Jan;124(1):25-34. 

[3] Döring M, Brenner B, Handgretinger R, Hofbeck M, Kerst G. (2014) Inadvertent intravenous administration  of maternal breast milk in a six-week-old infant: a case report and review oft he literature. BMC Res Notes; 7:17 

[4] Manias E, Kinney S, Cranswick N, Williams A, Borrott N. (2014) Interventions to reduce medication errors in pediatric intensive care. Ann Pharmacother; 48(10): 1313-31 

[5] Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P, Metnitz PG; Research Group on Quality Improvement of European Society of Intensive Care Medicine; Sentinel Events Evaluation Study Investigators. (2006) Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med; 32(10): 1591-8 

[6]  JCAHO. (2014) Tubing misconnections -  a persistent and potentially deadly occurrence. Joint Commission on Accreditation of Healthcare Organizations, USA. Sentinel Event Alert; 53: 1-3. 

[7] Simmons D, Symes L, Graves K. (2011) Tubing misconnections: normalization of deviance. Nutrition in Clinical Practice; 26(3): 286-293. 

[8] McDowell S, Mt-Isa S, Ashby D (2010) Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Qual Saf Health Care; 19(4): 341-5 

[9] Fraind DB, Slagle JM, Tubbesing VA, Hughes SA, Weinger MB (2002) Reengineering intravenous drug and fluid administration processes in the operating room: step one: task analysis of existing processes. Anesthesiology; 97(1): 139-47. 

[10] Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Ardakani MT (2008) Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study. Aust Crit Care; 21(2): 110-6. 

[11] Ferner RE, Langford NJ, Anton C, Hutchings A, Bateman DN, Routledge PA (2001) Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. Br J Clin Pharmacol; 52(5): 573-7. 

[12] Garnerin P, Pellet-Meier B, Chopard P, Perneger T, Bonnabry P (2007) Measuring human-error probabilities in drug preparation: a pilot simulation study. Eur J Clin Pharmacol; 63(8): 769-76 

[13] Parshuram CS, To T, Seto W, Trope A, Koren G, Laupacis A (2008) Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ; 178(1): 42-8. 

[14] Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T (2005) Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care; 14(3): 190-5. 

[15] Cohen H, Robins ES, Mandrack M (2003) Getting to the root of medication errors: Survey results. Nursing; 33(9): 36-45. 

[16] Wilson RMcL, Harrison BT, Gibberd RW, Hamilton JD (1999) An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust; 170(9): 411-5. 

[17] Johnson M, Sanchez P, Langdon R, Manias E, Levett-Jones T, Weidemann G, Aguilar V, Everett B. The impact of interruptions on medication errors in hospitals: an observational study of nurses. J Nurs Manag. 2017 Oct;25(7):498-507. 

[18]  National Patient Safety Agency. (2008). The National Patient Safety Agency annual report and accounts 2007 to 2008. London: The Stationery Office.

[19] Elliott RA, Camacho E, Jankovic D, Sculpher MJ, Faria R. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf. 2021 Feb;30(2):96-105. 

[20] Choi I, Lee SM, Flynn L, Kim CM, Lee S, Kim NK, Suh DC. Incidence and treatment costs attributable to medication errors in hospitalized patients. Res Social Adm Pharm. 2016 May-Jun;12(3):428-37. 

[21] Ehsani J, Jackson T, Duckett S (2006) The incidence and cost of adverse events in Victorian hospitals 2003-2004. Med J Aust 184(11): 551-55 

[22] Vincent C, Taylor-Adams S, Chapman EJ et al. (2000) How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ; 320(7237): 777-81. 

[23] Walsh EK, Hansen CR, Sahm LJ, Kearney PM, Doherty E, Bradley CP. Economic impact of medication error: a systematic review. Pharmacoepidemiol Drug Saf. 2017 May;26(5):481-497. 

[24] Parshuram CS, To T, Seto W, Trope A, Koren G, Laupacis A (2008) Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ; 178(1): 42-8. 

[25] Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T (2005) Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care; 14(3): 190-5. 

[26] Taxis K, Barber N,(2003) Etnographic study of incidence and serverity of intravenoius drug errors.BMJ 326:684 

[27] Dehmel C, Braune S, Keymann G, Baehr M, Langebrake C, Hilgarth H, Nierhaus A, Dartsch D, Kluge S (2011) Do centrallly pre-pared solutions achieve more reliable drug concentrations than solutions prepared on the ward? Intensive Care Med 2010-00231. R3 in press 

[28] Tissot E. Cornette C, Limat S, Maourand J, Becker M, Etievent J et al. (2003) Observational study of potential risk factors of medication administration errors. J Qual Improve 25(6):264-68 

[29] Vogel Kahmann I, Bürki R et al. (2003) Incompatibility reactions in the intensive care unit. Five years after implementation of a simple "color code system". Anasthesist 52(5):409-12 

[30] Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P et al. (2009). Errors in adminstration of parental drugs in intensive care units: multinational prospective study. BMJ 338:b814. doi:10.1136/bmj.b814 

[31] Taxis K (2005) Who is responsible for the safety of infusion devices? It's high time for action! QSHC 14(2):76 

[32] Rothschild JM, Keohane CA, Thompson S, Bates DW (2003) Intelligent Intravenous Infusion Pumps to improve Medication Administration Safety. AMIA Symposium Proceedings, p.992 

[33] Trissel LA (2011). Handbook on Injectable Drugs. 16th ed. Bethesda: American Society of Pharmacist. 

[34] Brigss J (2005) Strategies to reduce medication errors with reference to older adults. Best practice 9(4):1-6 

[35] Irajpour A, Farzi S, Saghaei M, Ravaghi H. Effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units. J Educ Health Promot. 2019 Oct 24;8:196. 

[36] Langebrake C, Hilgarth H (2010) Clinical pharmacists' interventions in a German University Hospital. Pharm World Svi 32(2):194-99 

[37] Kane-Gill SL, Jacobi J, Rothschild JM (2010)  Adverse drug events in intensive care units: Risk factors, impact and the role of team care. Crit Care Med 38(6): 83-89 

[38] Etchells E, Juurllink D, Levinson W (2008) Medication Errors: the human factor. CMAJ 178(1):63 

[39] Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. Separate Medication Preparation Rooms Reduce Interruptions and Medication Errors in the Hospital Setting: A Prospective Observational Study. J Patient Saf. 2021 Apr 1;17(3):e161-e168. 

[40] Jones JH, Treiber L (2010) When 5 rights Go Wrong. J Nurs Care Qual 25:240-247 

[41] Elliott M, Liu Y. (2010) The nine rights of medication administration: an overview. Br J NursMar 11-24;19(5):300-5. 

[42] Smeulers M, Verweij L, Maaskant JM, de Boer M, Krediet CT, Nieveen van Dijkum EJ, Vermeulen H. (2015) Quality indicators for safe medication preparation and administration: a systematic review. PLoS One. 2015 Apr 17;10(4):e0122695. doi: 10.1371 

[43] Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO