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Wrong administration technique is the drug error that most often harms patients, according to reports submitted to the United States Pharmacopeia's MEDMARX database. Examples of wrong technique include:


* not activating the drug product chamber into the main intravenous (I.V.) solution chamber to produce a thorough mixture


* crushing time-released tablets


* putting eyedrops into the wrong eye


* not flushing an I.V. line


* administering an I.V. drug too fast


* mixing a drug in an incompatible solution so that precipitate forms.



From 1999 through 2003, 508 (7%) of the 7,205 wrong technique errors reported were harmful. Of these harmful errors, 2 were fatal, 11 involved life-sustaining efforts, 55 involved prolonged or intensified treatment, and 8 may have caused permanent damage. Some type of intervention was required in 432 of the cases.


Performance or knowledge deficits and failure to follow procedures and protocols were the most common causes of administration technique errors. The researchers recommend more education and training for health care professionals who give medications. They also call for regular reviews of policies and procedures to make sure they're current and in line with best-practice guidelines.




Medication errors involving wrong administration technique, Joint Commission Journal on Quality and Patient Safety, JP Santell, DD Cousins, September 2005.