When intravenous medications are involved in ADEs, the harmful effects to the patient may occur more rapidly and be more severe than errors with oral medications, due the direct administration into the bloodstream. It is therefore important to use known safety practices with intravenous medications, solutions, and equipment that can minimize the risk of errors in administration. Many of the safe practices recommended here can easily be adopted, some of them at minimal or no cost to the organization.
Changes for Improvement
Standardize Intravenous Solutions
When several different strengths of intravenous solutions are available, it is far too easy to dispense or administer a different solution than was ordered. There is little need for multiple solutions because doses administered can be controlled by the flow rate set. Standardize each medication to just one strength of solution, or as few as possible, to decrease the risk of selecting the wrong one.
Use Pre-Mixed Intravenous Solutions
During the solution-mixing process, staff might easily select an incorrect amount of a drug or an incorrect type or amount of solvent, without realizing they’ve done so. The solution would then be mixed incorrectly, but the label would indicate the intended dose and solution, making the error invisible to the person administering the drug. Human factors studies have shown that the risk of such errors is especially high when workers are busy, distracted, tired, or working in an environment not designed for safety. Using pre-mixed solutions reduces the possibility of an adverse drug event due to a mixing error. Pre-mixing also saves time for pharmacy and nursing staff.
- Prepare only one standard solution for each medication, to prevent confusing different strengths of solution of the same medication. Physicians should work with the pharmacy in determining the strengths to prepare.
- Store only the standard strength on each unit.
- Prepare all intravenous solution bags in the hospital pharmacy.
- Make sure that the vendor supplying the pre-mixed solutions has good processes to prevent errors at its end. The processes should be at least the same as those you would use if mixing the solutions in your own organization.
- Maintain stocks and monitor them carefully, but have a well-defined plan for mixing solutions in case you run out.
- Require that only the standard solution be used except in rare cases that require peer review for any non-standard solution order, or for the record of any patient receiving a non-standard solution.
Prepare All Intravenous Solutions in the Hospital Pharmacy
Intravenous solutions must be mixed properly to ensure that the correct dose is administered to the patient. By preparing all solutions in the pharmacy, an organization can decrease the chance of errors. That’s simply because the fewer workers involved, the easier it is to maintain competency and consistent practice. People working in the pharmacy may encounter fewer distractions and interruptions than those in most patient care units. Intravenous solutions should arrive on patient care units in ready-to-use form, with no need for further manipulation by nursing staff.
- Remember that errors can happen just as easily in the pharmacy as in other units.
- Arrange work space and workflow so that staff preparing solutions are distracted as little as possible by noise, phone interruptions, and pedestrian traffic.
- Ensure that at least one trained staff member who routinely prepares intravenous solutions is always on duty. Inexperienced substitutes often commit errors.
- Have a plan to prepare solutions for off-shifts if your pharmacy is not open 24 hours a day.
Limit the Number of Floor Stock Intravenous Solutions
To reduce the chance of errors in selection of the appropriate solution that could lead to errors in intravenous administration of medications, keep the number of intravenous solutions available on patient care units to a minimum. A reliable system for dispensing and delivering solutions from the pharmacy will eliminate the need for many floor stock items. Only those few solutions that are commonly needed quickly or in emergencies should be in routine stock, and the supplies of those should be minimal.
- Review periodically the intravenous solutions each unit uses, to ensure that the floor stock items meet current needs.
- Customize the floor stock for the patient population on that unit.
- Ensure that administering staff members record in the medication administration record any intravenous solutions that they administer from the floor stock.
Use IV Pumps with Safety Features
Programmable pumps provide safety features to control the dose and amount of solution delivered to a patient. Intravenous solution bags that are hung without a pump do not have these safety features. Pumps control the amount of solution delivered to prevent inadvertent under dosing or overdosing, which can result in very serious harm to the patient.
- Use pumps that have a safety feature to prevent free-flow administration of solution.
- Use only one model of pump to avoid confusion and programming errors.
Use Smart Infusion Pumps
Infusion pumps with dose calculation software, sometimes referred to as “smart pumps,” offer the opportunity to identify and correct pump-programming errors. Incorrectly programming IV pumps is one of the most common types of medication error. When the error occurs with high-hazard drugs, it can result in serious adverse drug events since there is little ability to correct the error before it reaches the patient. Smart pumps offer the capability for a hospital to pre-program its standard concentrations and to program upper and lower dose limits. When implemented well, the pump will alert the nurse if the pump has been programmed outside of safe limits and will totally prevent administration of doses that are considered by the hospital to be extremely unsafe.
- Prior to deploying these pumps, standardize dosing units for a given drug (for example, agreeing to always dose nitroglycerin in terms of mcg/min or mcg/kg/min but not both). Asking a nurse to choose among several dosing units increases the risk of selection error.
- Prior to deploying these pumps, standardize drug nomenclature (for example, agreeing to always use the term KCl, but not Potassium chloride, K, Pot Chloride, or others). Asking the nurse to remember and choose among several possible drug names increases the risk of selection error.
- Perform a Failure Modes and Effects Analysis (FMEA) on the deployment of these devices.
- Ensure that the concentrations, dose units, and nomenclature used in the pump are consistent with that used on the Medication Administration Record (MAR), the pharmacy computer system, and the electronic medical record.
- Meet with all relevant clinicians to come to agreement on the proper upper and lower hard and soft dose limits.
- Monitor overrides of alerts to assess if the alerts have been properly configured or if additional quality intervention is required.
- Be sure the “smart” feature is utilized in all parts of the hospital. If the pump is set up volumetrically in the operating room but the “smart” feature is used in the ICU, an error may occur if the pump is not properly reprogrammed.
- Be sure there are upper and lower dose limits for bolus doses, when applicable.
- Engage the services of a human factors engineer to identify new opportunities for failure when the pumps are deployed.
- Identify a procedure for the staff to follow in the event a drug must be given which is either not in the library or when its concentration is not standard.
- Deploy the pump in all areas of the hospital. If a different pump is used on one floor and the patient is later transferred, this will create new opportunities for failure. Also, there may be incorrect assumptions about the technology available to a given floor or patient.
- Consider using “smart” technology for syringe pumps as well as large volume infusion devices.
Label All Distal Ports and Tubing on All Lines
Patients may sometimes have multiple lines in place. These may include peripheral intravenous lines, central lines and nasogastric tubes. Unfortunately, the ports on all of these are often the same size, which makes it very easy for staff to connect a syringe to the wrong port. In addition, the tubing and distal ports are often very close to each other. This can lead to oral medications being injected or tube feedings being connected into intravenous lines, either of which can lead to a serious adverse event. Placing labels on each distal port helps staff to identify the correct line when administering items or connecting tubing. Make sure to label the tubing as well, so that if it is disconnected from the port, whether by accident or intentionally, it is clear which connections match up. Use labels that look different for each type of line, distinguished by color or size. Remember, though, that some staff may be color-blind.
Use Tubing That Is Not Interchangeable
Some intravenous solution tubing may be interchangeable with enteral tubing; that is, each type of tubing can connect to the port intended for the other. This increases the risk of connecting tubing to the wrong port. Using tubing for intravenous solution that is not interchangeable with enteral tubing acts as a forcing function and makes it impossible for staff to accidentally connect the tubing to the wrong port.
Use Pre-Made Dose and Flow Rate Charts
When using medication in solutions, doses administered are affected by flow rates, so it is important to minimize the risk of error in setting flow rates. Providing pre-made dosing charts that list the appropriate flow rates to set for the dose requested can help staff quickly identify the proper flow rate without having to recall information from memory or do manual calculations.
- Laminate the dosing charts so that they will last longer.
- Provide copies of the dosing charts to all who order or administer medications, and place extra copies on patient care units.
Provide Dose-Calculation Aids on IV Solution Bag Labels
Administering medications in solution often requires calculations. Errors can happen easily, especially when staff members are busy, tired, or distracted. A calculation error can result in a significantly wrong dose, which may cause an adverse drug event. A calculation aid placed directly on the label means staff members administering medications need not make any calculations. A calculation aid on an infusion bag might list several different doses and the flow rates to set to achieve each one, based on the size of the bag and the concentration of the solution. Provide calculations for several different doses in case the medication order changes while the solution bag is still in use, but highlight the current dose ordered.
Use Oral Syringes for Oral Medications Only
Oral syringes are intended for administration of oral medications only, but unfortunately they often fit easily into intravenous line ports. This can lead to an error where an oral medication is administered accidentally into an intravenous line, which may lead to an adverse drug event. To avoid this risk, use oral syringes for oral administration only.
- Store oral syringes separately from other syringes, to prevent the chance of them being selected in error.
- Dispense all liquid medications in individual, ready-to-use, single doses. That way, nursing staff will never need to draw up medications using any syringes.
- Label oral syringes dispensed from the pharmacy with an "oral only" label on the tip or the plunger of the syringe so that the label must be removed prior to administration.
- Use oral syringes that have a different appearance from intravenous syringes, such as a different color.
Involve Patients in Checks of Intravenous Medications
Patients have an important role in the medication administration process. Patients who’ve asked questions about the medications they were about to receive have prevented many medication errors. Clinical personnel should always pay close to attention to the questions and concerns of patients. But they can go a step further by deliberately involving patients in the administration process. Before administering any medication, including intravenous ones, review the medication, its purpose, and the dose with the patient and ask him to verify that all are correct. The clinician should offer an opportunity for the patient to ask questions or raise concerns, and if anything is unclear, the administration should be delayed until everything is resolved. This extra line of defense before the last step can be crucial in preventing adverse drug events.
- Explain the purpose of the medication review clearly so patients understand the limits of their responsibility: It’s an extra safety step, not a shifting of the burden onto the patient’s shoulders.
- Involve the parents of pediatric patients in verifying medications to be administered intravenously to the patient, but remember to include the pediatric patients themselves if they are old enough participate too.