An adult hand holds a child's hand with a bandaged intravenous (IV) line.

Inadvertent administration of an oral liquid into a vein

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

This investigation emphasises that complex and fragmented medicine safety processes are putting patients across the country at risk. The report puts forward recommendations aimed at driving national improvement to reduce potentially fatal medication errors.

Please note that this investigation has previously been known as ‘Wrong route administration of an oral drug into a vein’.

Reference event

The investigation was launched after we were made aware of a nine-year old child wrongly administered an oral liquid drug into a vein during a planned renal biopsy. This is classed as a wrong route medication error.

Administration of medicine via the wrong route is defined as a ‘never event’ in the NHS. A never event is a serious incident that is entirely preventable.

The child stayed in the hospital for monitoring and was discharged with no adverse effects a day later. 

Investigation summary

The investigation reviews: 

  • The effectiveness of current processes for the storage of medicines.
  • Equipment design.
  • The prescribing, preparation, checking and administration of medication. 

It also considers the:

  • Contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein.
  • Effectiveness of current processes for implementation of local safety standards for invasive procedures.
Investigation report