Use of paediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis

Matthew Jones, Jonathan Clarke, Calandra Feather, Bryony Dean Franklin, Ruchi Sinha, Ian Maconochie, Ara Darzi, Nicholas Appelbaum

Research output: Contribution to journalArticlepeer-review

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Background: In a recent human reliability analysis (HRA) of simulated paediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs).

Objective: The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice (‘discrepancies’) that contributed to large magnitude and/or clinically significant MAEs.

Methods: Video recordings from the original study were re-analyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study.

Results: In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total; 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large magnitude MAEs.

Conclusion and Relevance: Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.
Original languageEnglish
Pages (from-to)1333-1340
Number of pages8
JournalAnnals of Pharmacotherapy
Issue number11
Early online date1 Mar 2021
Publication statusPublished - 1 Nov 2021


  • administration, intravenous
  • Guidelines as Topic
  • medication errors
  • nurses
  • patient safety
  • Practice Guidelines as Topic

ASJC Scopus subject areas

  • Pharmacy
  • Pediatrics
  • Emergency
  • Fundamentals and skills
  • Health Informatics
  • Drug guides
  • Pediatrics, Perinatology, and Child Health


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