USP Medication Safety Forum
Medication Errors
Involving Wrong
Administration
Technique
eports submitted to USPs MEDMARX database
R indicate that wrong administration technique is
the type of medication error that most often
results in harm to patients. Wrong administration tech-
nique errors result from an incorrect and/or improper
procedure used in the administration of a drug. Examples
of such errors are shown in Table 1 (page 529).
Of the 14 different types of error reported to MED-
MARX, wrong administration technique errors are infre-
quently reported but result in a disproportionate number
of harmful or fatal outcomes. From 1999 through 2003,
7,205 medication errors involved wrong administration
technique, of which 508 (7%) were harmful. In compari-
son, only 1.84% of all errors reported to MEDMARX in
the same five-year period were harmful.
Errors that involve wrong administration technique
were paired with other types of errors. In 1,257 cases,
wrong administration technique was most frequently
coupled with improper dose/quantity, followed by omis-
sion error, prescribing error, wrong route, wrong drug
preparation, wrong time, and unauthorized drug.
Findings
Severity of Error in Terms of Patient Outcomes
The MEDMARX program enables subscribing hospitals
and health systems to track errors in a standardized format
and compare themselves with this nationwide database.
MEDMARX categorizes errors according to the National
Coordinating Council for Medication Error Reporting and
Prevention severity index.1 The index has nine categories
528
September 2005
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
John P. Santell, M.S., R.Ph.
Diane D. Cousins, R.Ph.
Department Editor
James G. Stevenson, Pharm.D., College of Pharmacy,
University of Michigan, and University of Michigan Hospitals.
This department features medication error issues based on
data collected by the United States Pharmacopeia (USP).
from A through I. Categories B through D include errors
that occur but do not cause harm, and categories E
through I include harmful or fatal (category I) errors.
Errors in categories G through I are sentinel events. (The
Joint Commission definition of a sentinel event is any
unexpected occurrence involving death or serious physi-
cal or psychological injury, or the risk thereof.)2
Of the 7,205 errors involving wrong administration
technique, two resulted in death, 11 necessitated inter-
vention to sustain life, 8 may have resulted in permanent
harm, 55 necessitated prolonged or intensified treat-
ment, and 432 necessitated intervention of some type
(total of 508 harmful errors).
Because of their harmful outcomes, wrong administra-
tion technique errors affect the patients level of care,
often resulting in the initiation of or increase in patient
observation and vital signs monitoring, initiation of or
change in drug therapy, and initiation of laboratory test-
ing. Also reported were administration of an antidote,
transfer to a higher level of care, administration of oxy-
gen, and extension of the hospital stay by one to five days.
Location Where Errors Originated
The reported location of more than half (56%) of the
administration technique errors was a nursing (patient
care) unit. Other frequently reported locations include the
emergency department (6%), medical intensive care unit
(ICU; 4%), and outpatient clinic (3%). Coronary, neonatal,
and surgical ICUs; pediatrics; and oncology each were
mentioned as locations of the error in 2% of the reports.
Volume 31 Number 9
 Table 1. Examples of Errors Involving Wrong
Administration Technique
Not activating the drug product chamber into the
main intravenous (IV) solution chamber to produce
a thorough mixture
Crushing sustained-released tablets
Placing a patients eyedrops in the wrong eye
Administering an IV medication too rapidly
Not flushing an IV line
During the administration process, mixing a drug
in an incompatible solution so that a precipitate
forms
Reported Causes and Contributing Factors
For the administration technique errors reported in
1999 through 2003, 12,145 causes of error were identified
(Table 2, above). In many cases, more than one cause
was reported. Performance deficit was the most com-
monly reported cause of error and is essentially defined
as a cause that results when the person involved had the
requisite knowledge and training to perform the neces-
sary task but failed to do so. The most frequently identi-
fied contributing factors to administration technique
errors were distractions, inexperienced staff, and work-
load increase.
Medications
Of the 508 reports of harmful administration technique
errors, 442 identified a drug product (Table 3, page 530).
Actions Taken
Many of the reports of administration technique errors
identified actions that were taken to avoid similar errors,
such as informing the staff member who made the initial
error (62%), providing education or training (31%),
informing staff who were also involved in the error (20%),
and enhancing communication (12%). Five percent of the
reports said the patient or caregiver was informed, and
4% said the patients physician was informed.
Case Reports
The following case reports, which are based on
records in the MEDMARX database, highlight common
administration technique errors:
September 2005
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
Table 2. Common Causes of Medication
Administration Technique Errors Reported to
MEDMARX*
Cause of Error %
Performance deficit 45
Procedure/protocol not followed 30
Knowledge deficit 27
Monitoring inadequate/lacking 9
Communication 7
Pump, improper use 7
Dispensing device involved 6
* Based on 12,145 causes of error identified in 6,885 MEDMARX records
for 1999 through 2003.
A nurse administered undiluted potassium phosphate
injection by rapid IV push. The patient went into cardiac
arrest. Resuscitation attempts were unsuccessful.
A patient receiving IV vancomycin developed red man
syndromelightheadedness and an erythematous rash
on the face, neck, chest, and upper armsafter rapid
administration of a dose given in just several minutes, a
practice that was not consistent with the institutional
protocol for use of the drug.3 The rate of IV infusion of
0.9% sodium chloride injection (normal saline) was
increased to correct the patients hypotension. The symp-
toms resolved within several hours and did not recur
when subsequent vancomycin doses were infused for one
hour, the rate specified in the institutional protocol.
A patient in the neonatal ICU experienced asystole
after IV tubing containing residual potassium chloride
solution was flushed too rapidly (within 10 minutes).
Calcium gluconate was administered, and the infant was
successfully resuscitated.
An order was written for phytonadione 1 mg IV. The
pharmacy dispensed a 5-mg vial of the drug instead of
diluting the drug in preservative-free 5% dextrose injec-
tion or 0.9% sodium chloride injection for IV infusion at
a rate not to exceed 1 mg/min in accordance with estab-
lished procedures. A 1-mg dose was prepared on the
nursing unit using sterile water for injection containing
parabens (preservatives). It was given by rapid IV push,
and the patient experienced dyspnea, wheezing, chest
discomfort, and electrocardiographic changes. The
patient was treated with several medications to counter
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 Table 3. Leading Products Associated with pain was not well controlled. The dose of the morphine
Wrong Administration Technique Errors PCA was increased several times but the medication did
Resulting in Harm Reported to MEDMARX* not provide relief. After 10 days, nursing staff discovered
that the morphine PCA had been incorrectly loaded into
Generic Drug Product Name Ranking
the pump and that the infusion never entered the
Morphine 1
patients body. The error was corrected and the patient
Heparin 2 began receiving the increased (last ordered) dosage of
Dopamine 3 morphine. The patient shortly thereafter went into respi-
Vancomycin 4 ratory depression and was administered naloxone.
Phenytoin 5 A physician ordered phenytoin 1,500 mg IV for 2
Potassium chloride 6 hours. The pharmacy sent six vials containing 250 mg/5
Hydromorphone 7 mL to the nursing unit. The nurse diluted the phenytoin
Fentanyl 8 in 100 mL of 0.9% sodium chloride injection and infused
the admixture into a wrist vein. Severe necrosis of the
Insulin 9
hand developed, resulting in an extended hospital stay
* Based on 406 reports of administration technique error involving and eventual loss of the smallest finger. Phenytoin sodi-
patient harm and where a product was identified.
Designated as a high-alert medication based on the definition devel- um may be administered by direct IV injection into a
oped by the Joint Commission on Accreditation of Healthcare large vein through a large-gauge needle or catheter.5 IV
Organizationsmedications that have the highest risk of causing injury if
misused. MM.7.10: The hospital develops processes for managing high- infusion of phenytoin is not generally recommended
risk or high-alert medications [MM-19]. Source: Joint Commission on because of the danger of precipitation, but some clini-
Accreditation of Healthcare Organizations: 2005 Comprehensive
Accreditation Manual for Hospitals: The Official Handbook. Oakbrook cians suggest that this route is feasible if the infusion
Terrace, IL: Joint Commission Resources, 2004. fluid is suitable, as it was in this case; the drug is suffi-
Based on the number of times the drug product was reported.
ciently diluted (< 6.7 mg/mL, compared with 15 mg/mL in
this case); a 0.22- inline filter is used; and the admixture
the negative effects and recovered. It was unclear is administered immediately after preparation and
whether the symptoms were the result of the drug (that observed during infusion.
is, hypersensitivity, anaphylaxis), the diluent (only pre- In other cases, local phlebitis developed in a patient
servative-free 5% dextrose or 0.9% sodium chloride is receiving an IV phenytoin admixture through a Y-site
recommended by the manufacturer), or the rapid admin- connection into tubing containing 5% dextrose injection,
istration rate.4 with which phenytoin is incompatible. An inline filter
An infant receiving IV fentanyl by syringe pump devel- was not used, despite labeling on the phenytoin contain-
oped bradycardia and dusky skin. Positive-pressure ven- er with instructions for use of such a filter.
tilation had little effect. Rigidity was noted in the infant, Propranolol was given without checking the vital
and the nurse noticed that the fentanyl syringe contained signs in a patient who had been experiencing hypoten-
a smaller volume than it should have. The fentanyl infu- sion (systolic and diastolic blood pressure of 85 mmHg
sion was discontinued, naloxone was administered to and 60 mmHg, respectively) and lethargy. The patient
reverse the effects of the opiate, and oxygen saturation experienced orthostatic hypotension and fell when
improved immediately. Investigation revealed that the attempting to get out of bed.
syringe pump had been mistakenly programmed to deliv- A nurse crushed a 40-mg extended-release oxycodone
er the fentanyl solution at a rate of 1 mL/hr instead of 0.1 tablet (extended-release tablets should not be crushed
mL/hra rate that was 10 times what was ordered. This because crushing causes immediate release of the drug)
is an example of two types of errorwrong administra- and administered it to a patient. The patient experienced
tion technique and improper dose quantity. respiratory arrest and was successfully resuscitated
A patient receiving morphine from a patient- after intubation and the administration of naloxone to
controlled analgesia (PCA) pump complained that his reverse the opiate effects.

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Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
 A heparin IV infusion was ordered in accordance with
a dosing nomogram that called for a rate of 33 mL/hr.
However, the infusion was initiated at a rate of only 22
mL/hr. The error was discovered only because the
patients activated partial thromboplastin time (aPTT)
was not within the therapeutic range. A therapeutic
aPTT was achieved after the heparin infusion rate was
increased to 33 mL/hr. This case concerning a pump set-
ting, as in the earlier case of the infant given fentanyl
with an improperly programmed syringe pump, involves
not only wrong administration technique but also
improper dose or quantity.
Implications and Recommendations
Performance and knowledge deficits and failure to
follow procedures and protocols were the most com-
mon causes of administration technique errors report-
ed to MEDMARX. This suggests that health care
personnel involved in medication administration need
additional education and training. Furthermore, organ-
izations should regularly examine the policies and
procedures used to guide practitioners in proper drug
administration. Are the policies and procedures in con-
cert with current best practices? Have staff been ade-
quately trained on such policies? Is there an
assessment of staff competence and understanding on
these policies and procedures?
As illustrated by the case reports, many administra-
tion technique errors involve the IV route of administra-
tion. Errors with medications given by this route often
have the most serious outcomes. USP encourages organ-
izations to adopt standardized procedures for IV drugs in
all phases of the medication use process,6 including the
following elements:
Prescribers should order only standardized concen-
trations.
Protocols for ordering IV infusions should be clear
and should eliminate the possibility of calculation errors.
Pharmacies should always dispense unit dose rather
than multidose containers whenever possible.
Pharmacies should stock or prepare standardized
concentrations for all IV medications.
Solution containers should be labeled with the final
concentration of the product and the infusion rate as
appropriate. Appropriate warning labels (for example,
September 2005
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
incompatible with dextrose 5% or must be used by _)
need to be clearly visible.
On patient care units, preprinted charts of standard-
ized infusion rates should be readily accessible and reg-
ularly used.
Infusion devices and dispensing devices (for example,
devices for compounding parenteral nutrient solutions)
have become more numerous and sophisticated. The
proper use of IV infusion pumps and dispensing devices
should be addressed in staff training programs. A review
of errors involving opioid narcotics (for example, mor-
phine, fentanyl, hydromorphone) indicate that in many
cases, the health care practitioner may have done one of
the following:
Improperly loaded the PCA syringe/cartridge into the
pump, causing air or kinks in the tubing, resulting in lit-
tle or no drug reaching the patient
Incorrectly programmed the PCA pump, delivering
either an over- or underdose of the drug
Used the wrong IV tubing to attach the PCA to the
main IV line or improperly connected the PCA pump to
the patients IV site, causing the tubing to disconnect
The National Coordinating Council for Medication
Error Reporting and Prevention recommends that users
of medication administration devices be knowledgeable
about device function and limitations.7 USP encourages
the use of programmable infusion devices with cus-
tomized pump settings that meet institutional guidelines
for drug dosages for specific patient types and special-
ized care areas.6 To prevent staff confusion, organiza-
tions should avoid using different models of infusion
devices.
USP also recommends that infusion pump settings
should be independently confirmed by two qualified
individuals not only upon initiation of high-alert medica-
tions (for example, anticoagulants, cancer chemothera-
py agents, insulin, opiates) but for any required dosage
adjustment. Documentation of the medication infusion,
adjustments, and independent confirmation should be
readily apparent.
The use of proper and reasonable safety measures
can avoid free-flow errors. IV administration cassettes
that offer antifree-flow mechanisms should be rou-
tinely used. Free flow should be avoided when the
IV administration cassette has been removed from
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 the pump (for example, during a gown change or to
clear air).
Infusion tubing should be traced from the infusion
bag to the point of delivery to the patient. If multiple
infusions and pumps are used on the same patient, each
pump and respective tubing should be readily identifi-
able and labeled.
Reporting and sharing cases of error events can
contribute to the collective learning about a drugs
properties (for example, its physical compatibility in
various solutions or its propensity to cause adverse
effects depending on the rapidity with which it is
administered into the body). Subsequently, this learn-
ing can lead to improved and more appropriate admin-
istration techniques.
Summary
Wrong administration technique has consistently
been one of the most harmful types of medication error
in health systems participating in MEDMARX.
Administration technique errors typically are made by
References
1. National Coordinating Council for Medication Error Reporting
and Prevention: Index for Categorizing Medication Errors. Adopted
July 16, 1996, revised Feb 20, 2001. http://www.nccmerp.org/
medErrorCatIndex.html (last accessed Jun. 23, 2005).
2. Joint Commission on Accreditation of Healthcare Organizations:
Facts About the Sentinel Event Policy. http://www.jcaho.org/
accredited+organizations/sentinel+event/sefacts.ht. (last accessed
Jun. 23, 2005).
3. McEvoy G.K. (ed.): Vancomycin hydrochloride. In: AHFS Drug
Information 2003. Bethesda, MD: American Society of Health-System
Pharmacists, 2003, pp. 470477.
4. McEvoy G.K. (ed).: Phytonadione. In: AHFS Drug Information
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September 2005
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
nurses administering medications on the patient care
unit, although errors in administration technique also
occur in other phases of medication use and involve
other health care personnel and locations.
The most commonly reported causes of error have
been performance deficit, failure to follow procedures or
protocols, and knowledge deficit. Educating and training
health care personnel on proper administration tech-
niques and use of infusion pumps and dispensing devices
could reduce the risk of error. The drug products most
often associated with administration technique errors
and patient harm could be targeted in staff education
and training programs. J
John P. Santell, M.S., R.Ph., is Director, Educational
Program Initiatives, and Diane D. Cousins, R.Ph., is Vice
President, United States Pharmacopeia (USP) Center for
the Advancement of Patient Safety, Rockville, Maryland.
Please send correspondence to John Santell, M.S., R.Ph.,
jps@usp.org.
2003. Bethesda, MD: American Society of Health-System Pharmacists,
2003, pp. 35333535.
5. McEvoy G.K. (ed.): Phenytoin/phenytoin sodium. In: AHFS Drug
Information 2003. Bethesda, MD: American Society of Health-
System Pharmacists, 2003, pp. 21122115.
6. Hicks R.W., Cousins D.D., Williams R.L.: Summary of information
submitted to MEDMARX in the year 2002: The Quest for Quality.
Rockville, MD: USP Center for the Advancement of Patient Safety, 2003.
7. National Coordinating Council for Medication Error Reporting
and Prevention: Recommendations to Reduce Errors Related
to Administration of Drugs. http://www.nccmerp.org/council/
council1999-06-29.html?USP_Print=true (last accessed Jun. 23, 2005).
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