Dear Patient Safety Learning,
Inadvertent administration of an oral liquid medicine
into a vein (12017/009) HSIB.
PSL over view: Healthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environme