Medication errors represent a clear and significant danger in the health care setting, especially for those patients that are critically ill and hospitalized in an intensive care unit (ICU), where the probability of a damaging adverse drug event (ADE) due to error is more pronounced. Furthermore, intravenous (IV) medication errors present a distinct risk to patients, as approximately two out of three patients in the ICU are administered multiple IV drugs, which only increases the odds that an error will lead to an ADE. Because IV medications are far more likely to cause harm or death compared to other types of medication errors, this clearly magnifies the importance of having comprehensive and effective IV safety measures in place. While large-scale technology upgrades can offer broad-based safety, there are also small-scale solutions to help reduce or eliminate IV medication errors and the adverse drug events (ADEs) they produce.

Patient Risk and Facility Burden
Due to the complex nature of IV medications, safe administration hinges not only on accurate physician prescribing, pharmacist review, and nursing administration, but also on proper preparation and monitoring. While errors can occur for a variety of reasons and at varying points in the life of an IV medication, the most common point of error is during product preparation. Errors in this setting can affect administration rate, mixture, volume, and/or compatibility, and mistakes involving the determination or labeling of timing, route, or drug or diluent used to make a specific IV medication also can lead to significant ADEs. 

Another area of particular concern involves errors made during the administration of IV medication, largely due to the fact that the administration stage is the last chance to catch any errors. So, should a previous error go undetected or a new one be made, there is essentially no further opportunity to stop the IV preparation from affecting the patient. Depending on their severity, ADEs can cause temporary or permanent injury to the patient, require significant intervention to sustain life, and still may result in a patient’s death. The primary concern for patient safety notwithstanding, ADEs also consume valuable resources, such as staff and patient time, and additional expenses directly proportional to the severity of the ADE. Finally, ADEs compromise patient trust and are demoralizing to hospital staff.

Barriers to Implementing Safer IV Systems
There are several challenges that prevent the implementation of safer systems for intravenous medication use (see Table 1). Chief among these is a lack of standardization of and good process design for IV medication use.1 Many facilities use a wide variety of drug nomenclature, dosing units, dose limits, maximum infusion rates, weight limits, and volume limits within their facilities leading to obvious risk. For example, within IV smart pump libraries, there may be several different names listed for the same drug and each entry may list different dosage units.



Providing an additional challenge is the lack of common compliance thresholds and shared accountability for safety among members of different health care disciplines.1 The results of a 2005 study of early generation smart pumps indicated that the smart pumps had no measureable impact on serious medication error rates, which was owed in part to poor user compliance; this despite the fact that IV errors and ADEs were found to be frequent and could be discovered through proper use of the smart pump features.2 In some cases, alarms had been simply turned off or overridden. Clinicians are prone to the belief that they do not make mistakes and perceive smart pump safety functions and dose guiding libraries to be cumbersome and an obstacle to efficient workflow. This illustrates that no matter the degree of sophistication, human interaction with processes will create opportunities for error. 

The third major challenge to optimum IV medication safety is that health care professionals work in a high-volume, high-demand environment where safety may be sacrificed for other priorities.1 More specifically, the patient to staff ratio—whether they be nurses, pharmacists, or physicians—may not be conducive for the continual provision of quality IV medication care. The complexity of multiple IV medication therapies, without in-depth pharmacology knowledge, also makes flawless administration difficult. 

Implementation of IV Medication Safety Technology 
In order to combat the challenges to safe IV medication administration, both tangible and intangible factors must be brought to bear. With this in mind, the following elements are key to the effective implementation of an IV medication safety system: 

• The facility must foster a culture of safety for patients, caregivers, and all staff. This broad initiative should be every hospital’s governing mission. 
• Addressing a multidisciplinary issue requires input from all affected parties. Thus, a project management team should include physicians, pharmacists, nurses, respiratory therapists, and risk managers, as well as other members of senior leadership. In particular, a designated patient safety or medication safety officer becomes an important leader in managing and directing patient safety interventions.  
• To overcome the greatest challenge to IV medication safety, a hospital must formally standardize its intravenous drug nomenclature, concentrations, dosing units, and ranges. Standardizing IV concentrations is particularly effective in reducing the incidence of wrong concentration and wrong dose errors. 
• As hardware- and software-based systems have grown dramatically in recent years, the implementation of IV medication preparation and administration technology has become crucial to lasting safety initiatives. Successful integration of these elements requires open communication, collaboration, and dedication toward a mutual goal.

From a more concrete standpoint, the implementation of IV medication safety technology requires in-depth supplier and product assessment. Depending on each facility’s current level of technology adoption, the driving forces for selection should include estimates of the speed with which the adoption will impact the initial cost and ROI, the staff resources and time required for implementation, and the potential to reduce patient harm due to medication errors. The impact of a given technology on quality care, as well as its impact on nursing satisfaction and productivity, must also be considered. 

The most sophisticated IV safety networks require an implementation process that is usually applied over several years due to the scope of the individual systems. Quite often, implementation of a large-scale IV medication safety network begins with smart infusion pumps. Smart pumps are effective in reducing IV medication errors and often rank as the highest priority in the integration of a safety system. Generally, the second highest priority is the incorporation of eMAR and BCMA systems, both of which electronically record all aspects of IV medication administration. The natural subsequent step is to incorporate an inpatient CPOE system such that prescriptions can be written and transferred electronically, virtually eliminating errors related to incomplete and/or illegible orders.

The clear goal of any comprehensive IV medication safety technology network is to maintain a state of zero tolerance for errors; however, given that processes dependent on human action are inherently fallible, large-scale safety measures will only be as effective as the education, training, and maintenance of policies and procedures governing IV medication use. Redundant processes build in quality and safety; eg, having a second nurse check chemotherapy for correct patient name and dose, scanning medication bar codes during pharmacy dispensing, and scanning medication bar codes at the patient’s bedside. Building system redundancy into all processes is one way to ensure policy compliance, but there are additional actions the pharmacy can take to improve safety. 

Pharmacy-driven Safety Measures
Regardless of where a facility stands from a safety network adoption standpoint, several measures can be taken by individuals to reduce the rate of IV medication errors and thus reduce the rate of associated ADEs. Among the available forms of IV drug delivery systems, each has characteristics, benefits, and issues that should be compared to a facility’s operational needs in order to determine compatibility (see Table 2). For example, ready-to-use parenteral medications can increase accuracy and safety, as well as streamline workflow by reducing the number of steps for IV preparation, while also reducing medication waste. However, if your facility utilizes a significant amount of specialty IV products or primarily treats pediatric or neonatal populations, these standardized products might not be your best source to satisfy IV medication requirements. 



Developing a specific protocol for IV medication administration also can reduce error rates. This is a process wherein data analysis is an important aspect of process improvement. For example, studying where, when, and by whom errors are being made can lead to the creation of special, targeted educational criteria to address areas of deficiency, as opposed to blanket re-education and re-training. Specific protocols that define procedures for drug administration, such as IV push versus slow infusion, provide helpful information to the bedside provider. Disease management or treatment protocols, eg, ICU sedation or heparin-induced thrombocytopenia, that are crafted by multidisciplinary teams help impart expert knowledge for infrequently occurring or complex conditions. 

One area particularly deserving of attention is curbing ADEs involving high-alert medications. Of the more effective practices, minimizing the mixing of high-alert medications in unit and code situations, closely following USP <797> requirements for compounding high-alert preparations, and limiting the availability of concentrated electrolyte solutions have all proven to reduce ADEs associated with high-alert medications. Prevention of ADEs can also be achieved by requiring an independent double check of doses and pump settings when calculations are required.

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Conclusion
Adopting a wide range of safety initiatives in the critical care setting can significantly reduce the volume and severity of IV medication errors and any resulting ADEs. Implementing IV medication safety systems, standardizing drug names, standardizing concentrations, and purchasing ready-to-use medications are just a few solutions to drastically improve patient safety and contribute to operating efficiencies. Educating health care professionals and developing specific drug protocols can also foster an environment where medication errors are less likely to occur.

References

1. ASHP Reports: Proceedings of a summit on preventing patient harm and death from i.v. medication errors. Am J Health-Syst Pharm. 2008;65:2367-2379.
2. Rothschild JM, Keohane CA, Cook EF. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33(3):533-540.
3. Sanborn MD, Moody ML, Harder KA. Second consensus development conference on the safety of intravenous drug delivery systems-2008. Am J Health-Syst Pharm. 2009;66:185-192.

Kathryn Jenkins is a student at the University of Delaware studying biology and psychology. Her research interests include diagnostics and infectious disease and she intends to pursue a career in medicine. Kathryn has been employed by the pharmacy department at the Brigham and Women’s Hospital (BWH), Boston, Massachusetts, for the last several years.

John Fanikos, MBA, RPh, the director of pharmacy business and financial services at BWH, is also assistant professor of clinical pharmacy practice at Northeastern University and at the Massachusetts College of Pharmacy (MCP). He earned his pharmacy degree at MCP and his MBA degree at Northeastern.