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Article Excerpt
Limited research exists to identify best practice for administering intravenous continuous infusion (IVCI) medications or for dosage calculations by nurses. The Institute of Healthcare Improvement [IHI] (2003) and the Massachusetts Coalition for Prevention of Medical Errors (Massachusetts Hospital Association [MHA], 1999) encourage periodic education and known safety practices with IV medications to minimize the risk of errors in administration. The authors designed a workshop for the medical-surgical registered nurse (RN) staff at a 626 licensed bed, inner-city, Level 1 Trauma Center. The workshop included a review of evidence-based practice (EBP), recommended best-practice skills in administering IVCI medications, a tool kit, and clinical simulations. Participants' responses to the workshop and the clinical outcomes of this educational effort were evaluated.
The authors reviewed the literature (1997-2007) for research involving best practice for IVCI. The MEDLINE, CINAHL and Cochrane Library sites were reviewed, and 4,128 citations were obtained using the following key words: intravenous medication, adverse drug events, medication errors, intravenous medication errors, and nursing medication math calculations.
Adverse Drug Events
Over the last decade, regulatory, certifying, and consumer agencies have focused on medication errors and adverse drug events (ADE). The Institute of Medicine (IOM) issued the landmark publication, To Err is Human: Building a Safer Health System, which identified patient safety as freedom from accidental injuries such as adverse events (Kohn, Corrigan, & Donaldson, 1999). IOM recommendations (Brennan et al., 1991) indicated the most common adverse medical events involved medication administration. The National Coordinating Council for Medication Error Reporting and Prevention [NCC MERP] (2007) defined a medication error as a preventable event that may cause or lead to inappropriate medication use or patient harm. NCC MERP developed a Medication Error Index for Categorizing Errors (Hartwig, Denger, & Schneider, 1991) (see Table 1). The categories range from A to I, with A being the least injurious and I indicating an error that resulted in a patient death; this severity rating is used to measure ADE outcomes.
The Massachusetts Coalition for Prevention of Medical Errors (MHA, 1999) published best-practice recommendations for the state and adopted a systems-oriented approach to medication error reduction based on studies indicating errors are often the result of error-prone systems. Recommendations included a non-punitive atmosphere, unit-dose systems, pharmacy admixture system, removal of concentrated potassium chloride vials from nursing units, development of special procedures for high-risk drugs, orientation and periodic education on administering and monitoring medications, computerized physician order entry systems, electronic medication administration records, and bar coding. According to the Agency for Health Care Research and Quality (AHRQ, 2001), over 770,000 people in the United States are injured or die in hospitals from ADEs annually. The IHI's 100,000 Lives Campaign focused on safety practices that would save 100,000 lives annually (IHI, 2003). Recommendations for intravenous (IV) medication safety improvement included the following: conduct independent double checks, provide dose calculation aids on IV solution bag labels, institute a hospital IV admixture system, use IV smart infusion pumps with safety features, and utilize pre-made dose and flow-rate charts. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2004) cited patient safety standards and required health care professionals to focus more attention on managing risks associated with patient safety; standards included using infusion pumps, identifying high-alert medications, standardizing abbreviations, and using two patient identifiers.
Approximately 90% of hospitalized patients receive medications intravenously (Husch et al., 2005). Infusion pumps are used to deliver most IVCI and intermittent medications in the United States (Rothschild et al., 2005). The ADE Prevention Study (Bates et al., 1995) found a rate of 6.5 ADEs for every 100 admissions, with 28% of these preventable errors. This study identified medication administration by nursing as the second most common cause (38%) of ADEs. Inadequate drug knowledge, problems related to IV infusion pumps, and parenteral delivery problems were cited as the cause of errors (Rothschild et al., 2005).
The Preventing Medication Errors report (IOM, 2006) again raised awareness of the frequency and severity of medication errors. According to this report, medication errors injure more than 1.5 million patients each year and hospitalized patients are at risk for at least one medication error per day. The recent IHI campaign Protecting 5 Million Lives from Harm (IHI, 2007) aimed to avoid 5 million incidents of medical harm between December 2006 and December 2008. New interventions targeted high-alert medications, including anticoagulants, sedatives, opioids, and insulin. The momentum to "do no harm" in medical care continues to build with support of these initiatives.
Intravenous Continuous Medications
Human factor engineering. The AHRQ (2001) addressed human factors engineering, the interaction of humans with machines and complex systems. Administration of medications intravenously results in the most serious outcomes of medication errors (Hicks & Becket, 2006; Vanderveen, 2007), with 60% of the serious and life-threatening potential adverse drug events related to IV infusions (Vanderveen, 2005). Smart pumps that incorporated software were identified as one safety system (Steingass, 2004). The software guides the nurse through various drug menus, and guardrails offer alerts for dose ranges and calculations for dose and flow rate based on input by...
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