Variability in the concentrations of intravenous drug infusions prepared in a critical care unit

Intensive Care Med. 2008 Aug;34(8):1441-7. doi: 10.1007/s00134-008-1113-9. Epub 2008 Apr 22.


Objective: To quantify the variability in the concentration of drug infusions prepared on an intensive care unit and establish whether there was a relationship between the quality of syringe labeling and drug preparation.

Design: Audit carried out over 3 weeks in May 2006 and completed in May 2007.

Setting: The adult neurosciences critical care unit of a UK university teaching hospital.

Interventions: Daily collections of discarded syringes containing midazolam, insulin, norepinephrine, dopamine, potassium or magnesium.

Measurements and results: Residual solutions in the syringes were sampled and the concentrations measured. Syringe labels were inspected and awarded a score for labeling quality based on an 11-point scale. A total of 149 syringes were analyzed. Six of the magnesium syringes contained 4-5 times too much Mg(2+), presumably because of confusion about converting millimoles to grams. The majority of the other infusions differed from the expected concentration by more than 10%. Magnesium infusions were least likely to be properly labeled (p= 0.012), and there was a positive correlation between quality of syringe labeling and drug preparation (p=0.002). After the introduction of a new electrolyte prescription chart, magnesium and potassium preparation significantly improved but there was still substantial variability.

Conclusions: These findings present a strong argument for the use of pre-prepared syringes or standardized drug preparation and labeling systems. They also highlight once again the difficulties healthcare professionals encounter when dealing with different ways of expressing drug concentrations.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anticonvulsants / administration & dosage
  • Drug Labeling*
  • Electrolytes / administration & dosage
  • Humans
  • Infusions, Intravenous*
  • Intensive Care Units / statistics & numerical data*
  • Magnesium Sulfate / administration & dosage
  • Medical Audit / methods
  • Medical Audit / statistics & numerical data*
  • Medication Errors / prevention & control
  • Medication Errors / statistics & numerical data*
  • Syringes
  • United Kingdom


  • Anticonvulsants
  • Electrolytes
  • Magnesium Sulfate