Gaps in intravenous medication safety practices: A study on nurse compliance in Vietnam

Abstract

Introduction and objectives

Intravenous therapy is widely used in hospital settings, however, nurse practice compliance remains suboptimal in many contexts. Although standardized initiatives have been introduced to address this issue, gaps in regulatory guidance and empirical evidence persist in Vietnam. This study aimed to evaluate nurses’ compliance with newly implemented program and to identify factors associated with non-compliance in inpatient care settings.

Materials and methods

A cross-sectional descriptive study was conducted at the tertiary military hospital in Southern Vietnam. Data were collected from 255 nurses using a peripheral IV drug preparation and administration processes assessment form based on JCI standards.

Results

Compliance with standard IV medication preparation and injection procedures was 33.7% and 38%, respectively, with the mandatory step of “checking for drug interactions” achieved in only 38.8% of cases. Nurses with more than 10 years of experience demonstrated lower compliance with medication preparation procedures (AOR = 0.44, 95% CI: 0.20–0.96; p = 0.041). Significant differences in drug administration compliance were observed between emergency rooms and general wards (AOR = 0.31, 95% CI: 0.15–0.63; p = 0.001), weekdays and weekends (AOR = 0.42, 95% CI: 0.21–0.83; p = 0.001), and day and night shifts (AOR = 0.30, 95% CI: 0.14–0.62; p = 0.023), whereas gender, age, and professional level were not significantly associated.

Conclusions

Nurse compliance with both IV medication preparation and administration procedures were low. Continuous international training programs for all nurses is essential to ensure medication safety.

Resumen

Introducción y objetivos

La terapia intravenosa es frecuente en los hospitales, pero el cumplimiento de las prácticas de enfermería sigue siendo bajo en muchos contextos. En Vietnam, pese a iniciativas estandarizadas, persisten brechas normativas y de evidencia. Este estudio evaluó el cumplimiento de enfermeras con un programa recientemente implementado e identificó factores asociados al incumplimiento en atención intrahospitalaria.

Materiales y métodos

Se realizó un estudio descriptivo transversal en un hospital militar terciario del sur de Vietnam. Se incluyeron 255 enfermeras y se evaluaron los procesos de preparación y administración de medicamentos por vía intravenosa periférica mediante un instrumento basado en estándares JCI.

Resultados

El cumplimiento fue bajo: 33,7% para la preparación y 38,0% para la administración por inyección. La verificación de interacciones medicamentosas, paso obligatorio, se cumplió en solo el 38,8% de los casos. En el análisis multivariable, tener más de 10 años de experiencia se asoció con menor cumplimiento en la preparación (AOR: 0,44; IC 95%: 0,20-0,96; p = 0,041). Para la administración, el cumplimiento fue significativamente menor en urgencias frente a salas generales (AOR: 0,31; IC 95%: 0,15-0,63; p = 0,001), en fines de semana frente a días laborables (AOR: 0,42; IC 95%: 0,21-0,83; p = 0,001) y en turnos nocturnos frente a diurnos (AOR: 0,30; IC 95%: 0,14-0,62; p = 0,023). Sexo, edad y nivel profesional no se asociaron de forma significativa.

Conclusiones

En conclusión, el cumplimiento de los procedimientos IV fue insuficiente. Se recomienda capacitación continua para fortalecer la seguridad de la medicación.

Introduction

Intravenous (IV) therapy is widely used in inpatient care, with evidence indicating that up to 80% of hospitalized patients receive IV therapy during admission.¹ The preparation and administration of IV medicines are high-risk steps in the medication-use process, where failures in protocol compliance can lead to preventable harm.² Direct observational research has shown that medication errors during IV administrations are frequent – nearly 70% of observed administrations in one large study involved at least one error.³ Consistent compliance with standardized procedures, supported by supervision and actionable feedback, is therefore central to patient safety and quality of care; audit-and-feedback approaches have demonstrated small-to-moderate improvements in professional practice across healthcare settings.⁴

However, compliance remains suboptimal in many contexts. The study by Nguyen et al. (2015) which assessed errors in the preparation and use of intravenous drugs ranging from 53.9% to 90.2% across Southeast Asian countries.⁵ A noticeable, Schutijser et al. (2018) found Dutch compliance with safe injectable protocols stagnant at 22%, compliance with the proceedings ‘hand hygiene’ and ‘check by a second nurse’ remained low.⁶ In many developing countries, practical intravenous (IV) medication procedures often lack detailed guidance, simplified protocols, and effective benchmarks and no clear distinction between preparation and administration phases.⁷

In 2024, Military Hospital XX implemented the PRIME (Preventing Risks of Infections and Medication Errors in intravenous therapy) programme, a structured initiative developed with Joint Commission International (JCI) consultants and evaluated across 21 tertiary hospitals in South-East Asia using training cascades and ongoing audits. By prioritizing standardized nursing practices and reducing medication errors, the hospital seeks to align with international benchmarks in quality and safety.⁸ Therefore, this study aims to: (1) assess nurses’ compliance with PRIME standards in IV medication preparation and administration and (2) identify factors associated with non-compliance, in order to inform targeted improvement strategies and support broader implementation. In addition, the outcomes of the study can also be used to facilitate broader implementation of the program at the national level, to improve clinical effectiveness.

Material and methods

Study design

This cross-sectional, descriptive study was conducted from March to June 2024 in clinical departments at the tertiary military hospital in Southern Vietnam, using routine intravenous (IV) therapy, ensuring that a sufficient number of nurses regularly performed IV drug administration.

Participants

The study population comprised nurses who had a minimum of six months’ work experience in direct patient care; were responsible for administering IV drugs in the participating departments; and were present during the data collection period (six months is the minimum period for nurses to be able to grasp the process and experience clinical practice). Nurses at our hospital graduate from various training institutions and need time to understand and adapt to the hospital environment to become proficient in their work. Furthermore, according to regulations of the Vietnamese Ministry of Health, nurses must complete at least six months of practical training at an accredited healthcare facility to obtain an official practice certificate. Nurses on maternity or sick leave, as well as those on study leave or otherwise working off-site, were excluded. We used the sample size estimation formula for estimating a proportion when the population is known (according to Yamane Taro – 1967)⁹:

where:

• -

  n1: number of samples to be observed to assess the situation

• -

  N: population size or total number of nurses practicing intravenous infusion in the tertiary military hospital is 700 people

• -

  e: allowable error 5% (0.05)

Therefore,

A minimum sample size of 255 nurses was deemed necessary to reliably assess current IV drug administration practices. Convenience sampling was employed, and the sample was matched via staff codes to avoid duplication of participants. Each participating nurse was observed once during routine care; any observations involving emergency procedures were excluded.

Data collection instruments

Data were gathered using a structured two-part tool designed to capture both independent and dependent variables:

• 1.

  Demographic and Practice-Related Questionnaire (Independent Variables): This section collected personal characteristics of the nurses, including gender, age group, educational background, and length of service. Additionally, situational variables related to the specific IV therapy session were recorded to assess their association with compliance, including: time of administration (morning vs. afternoon), day of the week (weekday vs. weekend), department type (e.g., Internal Medicine, ICU, Surgery), and the type of patient room (General ward vs. Emergency room).

• 2.

  Peripheral Intravenous Practice Assessment Form (Dependent Variables): This tool evaluated the primary outcome of nurse compliance. Developed based on the PRIME (Preventing Risks of Infections and Medication Errors) Program Implementation Results Assessment Toolkit and the specific technical procedures of the Military Hospital, the form consisted of 21 criteria divided into two key stages: Drug Preparation (10 criteria) and Peripheral IV Administration (11 criteria). Each criterion was scored as “Compliant” or “Non-compliant”. The content validity of the tool was evaluated and approved by PRIME program experts and the hospital's nursing board to ensure alignment with JCI standards. The complete observation checklist detailing all variables and criteria is provided in Appendix 1.

The observers were selected as 20 Prime Champions of the Prime program, being head nurses or nurses with high level IV therapy skills, and were trained in the new standards and assessment form. Observations were conducted during all shifts (day, night, weekend). These criteria were incorporated into a custom-designed digital application for data collection to facilitate real-time observation. Nurses were not informed of the observation's exact objectives to minimize the Hawthorne effect (people change their behavior when they know they are being observed).¹⁰

Outcome measures

Observations were scored as Compliance (1) or Noncompliance (0) based on two thresholds. For Drug Preparation Practice: achieving ≥70% of the total possible score, and correctly completing three critical steps: (a) rechecking the complete prescription, (b) verifying drug interactions, and (c) labeling prepared medications. For Drug Administration Practice: achieving ≥70% of the total possible score, and correctly performing four essential steps: (a) confirming the correct drug, (b) identifying the correct patient, (c) checking the drug dosage and (d) flushing. In particular, the process of drug preparation and administration must be observed continuously.

The 70% threshold is the minimum requirement of the PRIME program, and also meets the continuing education regulations of the Vietnamese Ministry of Health, while the required steps represent stricter benchmarks to further reduce the risk of medication errors.

Data analysis

Data analysis was performed by the researcher. All data were entered, cleaned, and analyzed using STATA (version 19.0) (StataCorp, College Station, TX, USA). Descriptive statistics, including frequencies and percentages, were used to characterize the sample and overall compliance rates. Associations between variables were assessed using Chi-square tests, and significant relationships (p < 0.05) were further examined through multivariate logistic regression analysis. Results were reported with 95% confidence intervals.

Ethics approval

The study was reviewed and approved by the Institutional Review Board of Military Hospital XX (No. 738/GCN-HDDD, March 1, 2024). The study was conducted in accordance with the principles of the Declaration of Helsinki. Before conducting the study, the researchers informed the study subjects about the research process and data collection methods, sent consent forms to the subjects, and only observed those who agreed to participate. However, we did not announce this at the time of the study to avoid the Hawthorn effect.

Results

General information of participants

A total of 255/700 nurses from Military Hospital XX participated in the study, with the majority being female (75.3%). Most of nurses (52.2%) were between 21 and 30 years of age. Regarding educational attainment, 61.2% held a university or postgraduate degree, and the remaining 38.8% had completed intermediate- or college-level training. Over half of the respondents (52.9%) had been working in clinical settings for 1–5 years. Overall, their demographic characteristics, training level, and experience were completely similar to the nursing workforce in Vietnam hospitals. When considering the type of room in which care was delivered, 68.2% of nurses operated in general rooms, whereas 31.8% worked in emergency rooms. Notably, IV injections were predominantly administered in the morning (85.5%), underscoring the high demand for medication administration during this time (Table 1).

Table 1.

General information of participants (n = 255).

Characteristics of participants	Number(n)	Percentage(%)
Gender
Male	63	24.7
Female	192	75.3
Age group
21–30 years old	133	52.2
31–40 years old	77	30.2
>40 years old	45	17.6
Professional level
Intermediate – College	99	38.8
University and postgraduate	156	61.2
Working experience
1–5 years	135	52.9
6–10 years	71	27.9
>10 years	49	19.2
Departments type
Internal Medicine	93	36.5
ICU	86	33.7
Surgery	76	29.8
Type of patient room served
General room	174	68.2
Emergency room	81	31.8
Injection timing
Morning (7:00 AM–11:59 AM)	218	85.5
Afternoon (12:00 PM–17:00 PM)	37	14.5
Day of week
Weekday	234	91.8
Weekend	21	8.2

Drug preparation compliance of nurses on intravenous therapy

Overall medication preparation compliance is relatively low, only 33.7% of observations showed that overall compliance was satisfactory with medication preparation practices. In particular, only 38.8% of observations performed checking for drug interactions. Over half of those observed (52.9%) did not double-check prescriptions against patient medical records (Table 2).

Table 2.

Practice drug preparation compliance of nurses on intravenous fluid therapy in Military Hospital XX, Vietnam, 2024 (n = 255).

Characteristics	Compliance		Non-compliance
	Frequency(n)	Percent(%)	Frequency(n)	Percent(%)
Clean the injection cart thoroughly with a surface disinfectant	197	77.3	58	22.7
Prepare all necessary equipment	219	85.9	36	14.1
Sharps container	222	87.1	33	12.9
Safe medication preparation area	180	70.6	75	29.4
Hand hygiene	201	78.8	54	21.2
Double-check the prescription against the patient's medical record	120	47.1	135	52.9
Verify the completeness of the prescription*	191	74.9	64	25.1
Check for drug interactions*	99	38.8	156	61.2
Prepare the medication	206	80.8	49	19.2
Label the medication*	183	71.8	72	28.2
Practice of drug preparation	86	33.7	169	66.3

Drug administration compliance of nurses on intravenous fluid therapy

With four mandatory compliance steps, overall compliance with injection protocols was low, at only 38.0%. The results of observing four required steps for correct practice during the injection phase, including correct drug identification, correct patient identification, checking drug dosage was at a good level, 80%, separately flushing step was 66.7% (Table 3).

Table 3.

Practice of intravenous medication administration of nurses on intravenous therapy in Military Hospital XX, Vietnam, 2024 (n = 255).

Characteristics	Compliance		Non-compliance
	Frequency(n)	Percent(%)	Frequency(n)	Percent(%)
Correct drug identification*	216	84.7	39	15.3
Correct patient identification*	210	82.4	45	17.7
Dose verification*	203	79.6	52	20.4
Hand hygiene	190	74.5	65	25.5
Disinfecting the needle hub/3-way stopcock, injection port	191	74.9	64	25.1
Checking needle patency	181	71.0	74	29.0
Medication administration	213	83.5	42	16.5
Flushing (referring to flushing the IV line)*	170	66.7	85	33.3
Capping the needle hub with a new safety cap	162	63.5	93	36.5
Safely disposing of the needle	214	83.9	41	16.1
Providing patient education about the medication	204	80.0	51	20.0
Practice of intravenous medication administration	97	38.0	158	62.0

Associated factors with IV drug preparation and administration

Multivariate logistic regression analysis showed that while male nurses appear to have a slightly higher rate of satisfactory drug preparation and drug administration compliance, the difference is not statistically significant (p > 0.05). No statistically significant association was found between age group, professional qualification, or department type and nurses’ compliance rates (p > 0.05). However, nurses with >10 years of working experience had a lower compliance rate for medication preparation (AOR = 0.44; 95% CI: 0.20–0.96; p = 0.041), and nurses working in the emergency room had a significantly lower compliance rate for injection practice than in the general ward (66.1% vs. 35.8%, AOR = 0.31; 95% CI: 0.15–0.63; p = 0.001). Furthermore, temporal factors significantly impacted adherence, with lower compliance observed during weekends (AOR = 0.42; 95% CI: 0.21–0.83; p = 0.001) and night shifts (AOR = 0.30; 95% CI: 0.14–0.62; p = 0.023) compared to weekdays and day shifts, respectively (Table 4).

Table 4.

Associated factors with IV drug preparation and administration among nurses.

Variables group	Drug preparation			Drug administration
	Compliant	AOR (CI, 95%)*	p*	Compliant	AOR (CI, 95%)**	p**
Gender
Male	24 (38.1%)	1.20 (0.61–3.09)	0.585	36 (57.1%)	1.19 (0.61–2.31)	0.598
Female	62 (32.3%)	–	–	108 (56.3%)	–	–
Age groups
21–30 years old	44 (33.1%)	–	–	49 (36.8%)	–	–
31–40 years old	25 (32.5%)	1.11 (0.56–2.17)	0.755	32 (41.6%)	1.11 (0.57–2.16)	0.745
>40 years old	17 (37.9)	1.37 (0.61–2.33)	0.443	16 (35.6%)	0.79 (0.35–1.80)	0.591
Professional level
Intermediate – College	34 (34.3%)	–	–	50 (50.5%)	–	–
University and postgraduate	52 (33.3%)	0.98 (0.53–1.71)	0.950	94 (60.3%)	1.53 (0.83–2.82)	0.165
Working experience
1–5 years	54 (40.0%)	–	–	54 (40.0%)	–	–
6–10 years	19 (26.8%)	0.62 (0.32–1.22)	0.169	23 (32.3%)	0.65 (0.33–1.28)	0.218
>10 years	13 (26.5%)	0.44 (0.20–0.96)	0.041	20 (40.8%)	0.84 (0.30–1.75)	0.648
Department type
ICU	37 (39.8%)	0.82 (0.42–1.61)	0.575	37 (43.0%)	0.62 (0.31–1.25)	0.185
Internal	32 (37.2%)	–	–	53 (57.0%)	–	–
Surgery	17 (22.4%)	0.48 (0.22–1.06)	0.070	54 (71.1%)	0.99 (0.48–2.04)	0.987
Type of room
Regular	52 (30.0%)	–	–	115 (66.1%)	–	–
Emergency	34 (41.0%)	1.54 (0.80–2.96)	0.187	29 (35.8%)	0.31 (0.15–0.63)	0.001
Day of week
Weekday	71 (39.2%)	–	–	82 (45.3%)	–	–
Weekend	15 (20.3%)	0.42 (0.21–0.83)	0.013	15 (20.3%)	0.33 (0.16–0.65)	0.001
Working shift
Day shift	74 (40.0%)	–	–	80 (43.2%)	–	–
Night shift	12 (17.1%)	0.30 (0.14–0.62)	0.001	17 (24.3%)	0.46 (0.23–0.89)	0.023

Abbreviations: AOR: adjusted odds ratio (when applicable); CI: confidence interval; ref = reference group. p-Values <0.05 are considered statistically significant. Morning (7:00 AM–11:59 AM), Afternoon (12:00 PM–17:00 PM).

*

Logistic regression results: −2 Log likelihood = 155.95906, Pseudo R² = 0.1051, LR chi²(11) = 34.25, p = 0.0003. Hosmer–Lemeshow Test sig: 0.3131.

**

Logistic regression results: −2 Log likelihood = −148.48271, Pseudo R² = 0.1234, LR chi²(11) = 41.48, p = <0.0001. Hosmer–Lemeshow Test sig: 0.6726.

Discussion

This study observed the nurses’ IV preparation and injection practices in the tertiary military hospital in Southern Vietnam, through a custom-designed digital application for data collection. The findings demonstrated overall non-compliance rate of the drug preparation and administration process in our study was 66.3% and 62% respectively. This aligns with the study by Nguyen et al. (2015) which assessed errors in the preparation and use of intravenous drugs ranging from 53.9% to 90.2%.⁵ However, our finding is higher than the results of the PRIME program study in 21 hospitals of 7 Asian countries, which reported a non-compliance IV practice rate of 32%.⁸ Since this program was previously implemented in international standard hospitals, it provides a robust benchmark for our assessment. In the national context, where IV therapy is regularly viewed as a single combined process, our hospital is a pioneer in distinctly separating medication preparation from administration for quality assessment. This granular approach allowed us to expose specific compliance gaps that might have been obscured in a traditional combined model. Thus, it underscores the importance of evaluating these two processes independently to better understand the distinct safety risks associated with each step. In addition, in the drug preparation process, the checking for drug interaction has the lowest success rate, which is similar to the study by Smithburger et al (2012).¹¹ This is completely appropriate in the context of the lack of attention to drug error management activities.

The compliance rate with intravenous injection procedures in our study was lower with those reported by Tolera et al. (2024),¹² who observed a 56.3% satisfactory practice rate among pediatric emergency nurses in public hospitals. Similarly, this also aligns with the high patient-to-nurse ratios commonly observed in public hospitals in Vietnam. Nevertheless, this result is higher than the study by Schutijser et al. (2018),⁶ which observed a compliance rate of 19%–22% in safe injectable medication administration protocols in Netherlands, with improvements following targeted interventions. Our findings further highlight the specific challenges in Vietnam in the management of intravenous drug practice.

In this study, we did not find the significant association between gender, age, education level and the nurses compliance to both procedures, which mirrors the study of Tabatabaee et al. (2022).¹³ However, we identified characterized factors associated with nurse compliance to the drug preparation and injection process, including seniority, room type, working day, working shift. Notably, medication preparation protocol compliance was significantly lower in nurses with more than 10 years of experience, a finding that is in contrast to the results of a 2020 study in Ethiopia¹⁴ and a study by Westbrook et al. (2011),³ which suggested that increased nursing experience typically reduces the risk of serious clinical deviations. A possible explanation for this difference may be that our hospital has just adopted new standard procedures, while nurses with many years of experience tend to practice out of habit, leading to non-compliance with the new procedures. Nurses working in the emergency room had significantly lower compliance to injection practices than those working in the general ward, this difference may be due to the fact that emergency room nurses often face higher workloads and higher pressure, leading to a higher likelihood of skipping steps and making errors. In addition, studies about medication errors in Ethiopia (2020) and Saudi Arabia showed that night shift nurses were five times more likely to make errors than day shift nurses,¹⁴ especially on weekends.¹⁵ It can be speculated that, on night and weekend shifts, nurses may have more difficulty maintaining concentration and strict adherence to protocols due to fatigue or higher workloads with fewer staff.

We acknowledge certain limitations in this study, specifically the use of a cross-sectional design with convenience sampling. However, the strength of this study lies in the high reliability of the data, ensured by the head nurses or nurses who served as observers with a high level of expertise and had been trained in the new assessment standards, supported by a custom-designed digital application to facilitate accurate evaluation. Additionally, our study identifies areas for quality improvement interventions, enabling our hospital to develop a structured patient safety training program, similar to the proposal in the study by Kuitunen et al. (2021),¹⁶ Tsegaye et al. (2020),¹⁴ leading to better intervention outcomes after the program. Continuous training programs based on updated, international standards for all nurses are essential to enhance nursing practice competence and thereby prevent medication errors in IV therapy. Future research utilizing multi-center studies with larger sample sizes is warranted to validate these findings across public and private sectors, while further investigating broader barriers to compliance such as nurse characteristics, patient needs, and the working environment.

Conclusion

Nurse compliance with both IV medication preparation and administration procedures was low, particularly in critical steps such as checking for drug interactions. Notably, the determinants of non-compliance differed by phase: high seniority (>10 years) was significantly associated with poor preparation compliance, whereas situational factors – such as working in emergency departments, on weekends, or during night shifts – were the primary drivers of lower administration compliance. These findings highlight a significant gap in medication safety practices and underscore the urgent need for targeted interventions. Implementing continuous, standardized training programs is essential to improve adherence to best practices and reduce the risk of medication errors in intravenous therapy.

Authors’ contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Tran Minh Tuan, Nguyen Viet Dang Khoa, Le Thi Huynh Nhu, Luu Thi Binh, Luong Bao Khanh, and Nguyen Thi Hoai Thu. The first draft of the manuscript was written by Tran Minh Tuan and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Military Hospital 175 (No. 738/GCN-HDDD, March 1, 2024).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

The authors affirm that human research participants provided informed consent for publication of the data included in this manuscript.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Declaration of competing interests

The authors have no relevant financial or non-financial interests to disclose.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.