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Inadvertent Administration of an Oral Liquid Medicine into a Vein.

Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.

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April 1, 2019

Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.

Wrong route medication administration is a never event. This report examined the context, organizational and human factors that contributed to the accidental intravenous administration of an oral solution into a pediatric patient. Safety recommendations include medication safety training, standardized administration processes, and elevation of the medication safety officer role. 

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Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.

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