Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting.

OBJECTIVES: Assess interventions' impact on preventing IV infusion identification and disconnection mix-ups. DESIGN: Experimental study with repeated measures design. SETTING: High fidelity simulated adult ICU. SUBJECTS: Forty critical care nurses. INTERVENTIONS: Participants had to correctly identify infusions and disconnect an infusion in four different conditions: baseline (current practice); line labels/organizers; smart pump; and light-linking system. MEASUREMENTS AND MAIN RESULTS: Participants identified infusions with significantly fewer errors when using line labels/organizers (0; 0%) than in the baseline (12; 7.7%) and smart pump conditions (10; 6.4%) (p < 0.01). The light-linking system did not significantly affect identification errors (5; 3.2%) compared with the other conditions. Participants were significantly faster identifying infusions when using line labels/organizers (0:31) than in the baseline (1:20), smart pump (1:29), and light-linking (1:22) conditions (p < 0.001). When disconnecting an infusion, there was no significant difference in errors between conditions, but participants were significantly slower when using the smart pump than all other conditions (p < 0.001). CONCLUSIONS: The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency.

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

BACKGROUND: Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. OBJECTIVE: The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. METHODS: The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. RESULTS: Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. CONCLUSIONS: Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required.

Vasopressor stewardship: a case report and lesson shared.

A case report, focused on vasopressor use and presented in this article, is likely to resonate with many critical care nurses. In this article the authors describe opportunities to enhance safety with vasopressor therapy. Specifically, the goal of improving communication among physicians, nurses, and pharmacists around desired endpoints for vasopressor therapy, triggers for reassessment of the therapeutic strategy and cause of the patient's shock was identified as an area for improvement. A form piloted within an organization for use during multidisciplinary rounds and key findings is shared. Vasopressors constitute the mainstay of therapy for nearly every hemodynamically unstable patient in critical care. It is hoped that the lessons and information shared help empower critical care nurses to facilitate vasopressor stewardship within their facilities and, ultimately, enhance patient safety.

Multiple Intravenous Infusions Phase 2a: Ontario Survey.

BACKGROUND: Research conducted in earlier phases of this study prospectively identified a number of concerns related to the safe administration of multiple intravenous (IV) infusions in Ontario hospitals. OBJECTIVE: To investigate the potential prevalence of practices or policies that may contribute to the patient safety risks identified in Phase 1b of this study. DATA SOURCES AND REVIEW METHODS: Sixty-four survey responses were analyzed from clinical units where multiple IV infusions may occur (e.g., adult intensive care units). Survey questions were organized according to the topics identified in Phase 1b as potential contributors to patient harm (e.g., labelling practices, patient transfer practices, secondary infusion policies). RESULTS: Survey results indicated suboptimal practices and policies in some clinical units, and variability in a number of infusion practices. Key areas of concern included the following: use of primary IV tubing without back check valves when administering secondary infusions, administration of secondary infusions with/as high-alert continuous IV medications, potential confusion about how IV tubing should be labelled to reflect replacement date and time, interruptions to IV therapy due to IV pump and/or tubing changes when patients are transferred between clinical units, coadministration of continuous or intermittent infusions on central venous pressure monitoring ports, variability in respondents' awareness of the infusion pump's bolus capabilities. LIMITATIONS: Due to the limited sample size, survey responses may not be representative of infusion practices across Ontario. Answers to some questions indicated that the intent of the questions might have been misunderstood. Due to a design error, 1 question about bolus administration methods was not shown to as many respondents as appropriate. CONCLUSIONS: The Ontario survey revealed variability in IV infusion practice across the province and potential opportunities to improve safety.

Multiple Intravenous Infusions Phase 2b: Laboratory Study.

BACKGROUND: Administering multiple intravenous (IV) infusions to a single patient via infusion pump occurs routinely in health care, but there has been little empirical research examining the risks associated with this practice or ways to mitigate those risks. OBJECTIVES: To identify the risks associated with multiple IV infusions and assess the impact of interventions on nurses' ability to safely administer them. DATA SOURCES AND REVIEW METHODS: Forty nurses completed infusion-related tasks in a simulated adult intensive care unit, with and without interventions (i.e., repeated-measures design). RESULTS: Errors were observed in completing common tasks associated with the administration of multiple IV infusions, including the following (all values from baseline, which was current practice): setting up and programming multiple primary continuous IV infusions (e.g., 11.7% programming errors)identifying IV infusions (e.g., 7.7% line-tracing errors)managing dead volume (e.g., 96.0% flush rate errors following IV syringe dose administration)setting up a secondary intermittent IV infusion (e.g., 11.3% secondary clamp errors)administering an IV pump bolus (e.g., 11.5% programming errors)Of 10 interventions tested, 6 (1 practice, 3 technology, and 2 educational) significantly decreased or even eliminated errors compared to baseline. LIMITATIONS: The simulation of an adult intensive care unit at 1 hospital limited the ability to generalize results. The study results were representative of nurses who received training in the interventions but had little experience using them. The longitudinal effects of the interventions were not studied. CONCLUSIONS: Administering and managing multiple IV infusions is a complex and risk-prone activity. However, when a patient requires multiple IV infusions, targeted interventions can reduce identified risks. A combination of standardized practice, technology improvements, and targeted education is required.

Drug name alert: potential for confusion between pradax and plavix.

In this article, the authors highlight an incident that involved a mix-up between the oral anticoagulant medication Pradax (dabigatran etexilate) and the antiplatelet medication Plavix (clopidogrel). Because critical care nurses may admit or care for patients who are receiving (or have received) one of these medications, it is important that they be aware of the potential for confusion between these two drug names throughout the medication-use process.

ALERT: mix-ups between conventional and lipid formulations of amphotericin B can be extremely dangerous.

In this column, the authors review Amphotericin B incidents reported Although amphotericin B may be less commonly used today because to ISMP Canada. In particular, we focus on incidents reported to have of alternative antifungal agents available, incident reports suggest resulted in patient harm due to mix-ups between the conventional there continues to be a need to alert practitioners to the different (non-lipid)formulation and lipid formulations of amphotericin B. formulations, and to implement system safety strategies.

Hospital-acquired acute hyponatremia and reports of pediatric deaths.

Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors.

Pharmaceutical bar coding: moving forward in Canada.

The purpose of this article is to provide an update on the status of automated identification (e.g., bar coding) of pharmaceutical products manufactured for distribution within Canada.

ALERT: Revatio is another brand name for sildenafil.

In this column, the authors highlight a medication incident that occurred with Revatio (sildenafil), along with the learnings and recommendations from a previously published ISMP Canada Safety Bulletin. It is well-known to health care practitioners that use of nitroglycerin therapy is contraindicated in patients taking sildenafil (commonly known as Viagra). Many health care practitioners may be unaware that sildenafil is also marketed under the brand name Revatio for treatment of primary pulmonary hypertension or pulmonary hypertension secondary to connective tissue disease. The following incident signals the need to heighten the awareness that Revatio is a brand name for sildenafil.

A near miss involving cyclophosphamide.

Reports of near miss incidents offer valuable learning opportunities. In this article, the authors highlight a near miss incident that occurred in an intensive care unit with the cytotoxic medication cyclophosphamide, for a non-oncology indication. The learning from this incident, including recommendations, is shared.

National collaborative: Top five drugs reported as causing harm through medication error in pediatrics.

The Canadian Association of Paediatric Health Centres (CAPHC) and the Institute for Safe Medication Practices Canada (ISMP Canada) are working collaboratively to enhance the safety of pediatric medication use. Eleven CAPHC member organizations submitted data on more than 4,000 medication incidents to ISMP Canada for the period October 2005 to June 2008, 305 of which were reported as resulting in harm. From this, the top five drugs causing harm through medication error and contributing factors to the incidents were identified. In this article, we intend to inform critical care practitioners of the medication incident analyses and the collaborative pediatric patient safety initiatives underway.

Desmopressin (dDAVP) incident signals the need for enhanced monitoring protocols.

In this article, the authors highlight the circumstances surrounding the death of a young adult neurosurgical patient, recently reported to ISMP Canada. The incident signals the need for enhanced safeguards for patients receiving desmopressin (also known as dDAVP) and intravenous therapy. The authors present information from a recent ISMP Canada Safety Bulletin relevant to critical care, including an outline of potential contributing factors and suggested recommendations.

Preventing substitution errors involving high-concentration heparin products.

Critical care practitioners routinely administer heparin for various indications (e.g., treatment of acute coronary syndrome, venous thromboembolism prophylaxis, line maintenance) and by various routes (e.g., intravenously, subcutaneously). Knowledge of reported incidents involving high-concentration heparin products can increase practitioner awareness of risks for error-induced injury associated with storage and administration of anticoagulants, such as heparin. Substitution errors leading to administration of an incorrect dose of unfractionated heparin are highlighted and suggestions for system-based error prevention strategies are provided.

Epidural medications given intravenously may result in death.

Anesthetics, such as bupivacaine, intended for epidural analgesia can cause severe cardio- and neurotoxicity when inadvertently administered via the intravenous route. This article highlights a case report and the dangers associated with the inadvertent administration of an epidural solution intravenously. Multiple system-based strategies for prevention are provided.

Neuromuscular blocking agents: enhancing safety by reducing the risk of accidental administration.

Neuromuscular blocking agents (NMBAs) are often found as ward stock in critical care units to ensure their availability in case of urgent need. The unintentional administration of an NMBA to a non-intubated and non-ventilated patient can result in severe permanent injury or death. Incidents involving mix-ups with NMBAs have occurred within and outside of critical care units. Case reports are highlighted with the intent to increase practitioner awareness of situations that could lead to similar errors and to promote changes in the critical care environment in order to enhance medication safety with NMBAs.

Enhancing safety with potassium phosphates injection.

The inadvertent administration of concentrated potassium chloride resulting in patient death is well-documented in Canada and other countries. Vials of potassium phosphates contain more than twice the concentration of potassium compared to vials of potassium chloride concentrate. If inadequately diluted or administered too rapidly, intravenous potassium phosphate can also lead to serious patient harm. This article contains information reprinted with permission from an ISMP Canada Safety Bulletin (ISMP Canada, 2006, April 25) for the purpose of enhancing safety with potassium phosphates injection.

Implementing system safeguards to prevent error-induced injury with opioids (narcotics): an ISMP Canada collaborative.

Institute for Safe Medication Practices Canada (ISMP Canada) is involved in collaborative initiatives focusing on opioid safety in two Canadian provinces: Ontario and Alberta. Baseline survey responses from these provinces indicate opportunities for improvements to the opioid system that might be applicable nationally. Information about the Ontario project and preliminary analysis of follow-up survey results from that province are shared here, to increase awareness and create further national impetus for the enhancement of safeguards in the use and management of opioids.