Factors predictive of intravenous fluid administration errors in Australian surgical care wards

Intravenous fluid administration practice among nurses and midwives working in public hospitals of central Ethiopia: A cross-sectional study

Intravenous fluid administration is the most common invasive procedure widely practiced in hospital settings. Globally, approximately 25 million people receive intravenous fluid therapy. Different factors affect nurse's intravenous fluid administration practices; that it may influences on the patient's outcome, increase morbidity and mortality. Previous study indicates that healthcare providers especially in developing countries have skills gap related to intravenous fluid administration. The purpose of this study was aimed to assess the intravenous fluid administration practices and its associated factors among nurses and midwives working in public hospitals of West Shewa zone, Central Ethiopia.

Materials and methods

An institution-based cross-sectional study design was employed among 396 nurses and midwives in public hospitals in West Shewa zone, Central Ethiopia, from March 1 to 31, 2019. A Simple random sampling was used to select study participants using structured self-administered questionnaire, and observational checklist. The logistic regression model was used to identify association, and odds ratio was used to test the strength of the associations with outcome variable and predictor variables.

Results

In this study, 59.3% (95%CI = 54.7%-64.5%) participants was had inadequate intravenous fluid administration practice. Inadequate knowledge (AOR 2.1; CI 95% = 1.36-3.36), being untrained (AOR 1.7; 95% CI = 1.04-2.86), unavailability of supervision (AOR 1.8; CI 95% = 1.14-2.99), and absence of incentives and promotion for nurses and midwives (AOR 2.1; CI 95% = 1.19-3.62) were significantly associated with outcome variable.

Conclusion

Nearly seven in ten participants in the study setting were inadequate intravenous fluid practice. Inadequate knowledge, training, and absence of supervision by senior staffs, and absence of incentives and promotion for nurses and midwives were the main factors affecting intravenous fluid administration practice. Refresher courses, supervision, incentives and promotions were needed to nurses and midwives for an improvement of the intravenous fluid administration practice.

Flow rate accuracy of infusion devices within healthcare settings: a systematic review

Background

One in five patients admitted to the hospital treated with intravenous (IV) fluid therapy suffer complications due to inappropriate administration. Errors have been reported in 13-84% of the preparation and administration of IV medications. The safe delivery of IV fluids requires precise rate administration.

Objectives

This systematic review aims to determine the accuracy of infusion sets and devices and examine the factors that affect the flow rate accuracy of devices.

Data Sources and Methods

Six databases (CINAHL, MEDLINE PubMed, EMBASE, Web of Science and Cochrane Database of systematic reviews) were systematically searched. Search terms included infusion pumps, infusion devices, flow rate accuracy, fluid administration rate, gravity-led infusion set and fluid balance. Studies were included if they examined infusion devices' flow rate accuracy and drop rates for fluids or non-oncological drugs. Findings were tabulated and synthesised qualitatively. The quality of the studies was examined based on the design of the studies due to their heterogeneity.

Results

Eight studies were included: Four studies were conducted on human subjects in the hospital environment; studies recruited 182 participants between the ages of 18 and 94 years. Two studies examined flow rate accuracy in recruited patients across 509 observations and 2387 drip hours. No trials prospectively assessed the accuracy of infusion pumps in the clinical domain, and no studies were reported on patient safety outcomes. Four studies examined the impact of mechanical and physiological factors on the flow rate accuracies of infusion devices. Height and back pressure simulated vibrating conditions, the viscosity of IV fluid and the positions of patients were reported to have a significant impact on infusion volume and flow rates of infusion devices. Additionally, giving sets that vary from the manufacturer's specifications are reported to increase error percent by 10-20%.

Conclusion

Infusion devices are an important source of error in administering IV fluids. Yet, there needs to be more prospective trial data to support their clinical accuracy and the impact on patient outcomes. Future flow variability and accuracy studies should capture their impact on patient safety and clinical outcomes.

Reliability of Marked Scales on Intravenous Fluid Plastic Bags

Precise fluid administration is important to prevent hypo- or hypervolemia. However, the accuracy of scales marked on intravenous (IV) fluid plastic bags had remained unknown. Ten 1 L sized IV crystalloids were prepared from each of three manufacturers (H, J, and D). At each scale, the actual volume of the IV fluid was measured. Differences with the measured volumes for each scale were investigated between the three manufacturers. All initial total volume was greater than 1 L. Except for the full-filled level, H overfilled, whereas J and D filled less. For J and D, the maximal differences between the scale and the measured volume were about 200 mL. Fluid volumes of each scale were significantly different among the three manufacturers (P < 0.001). It is inaccurate to measure the amount of fluid depending on the IV bag scales. Clinicians must use electronic infusion pumps for accurate fluid administration.

Interdisciplinary knowledge gaps on intravenous fluid management in adult patients: Survey among physicians and nurses of a university hospital

RATIONALE

Intravenous (IV) fluids are frequently involved in iatrogenic complications in hospitalized patients. Knowledge of IV fluids seems inadequate and is not covered sufficiently in standard medical education.

METHODS

Two surveys were developed, based on the 2016 British National Institute for Health and Care Excellence guideline 'IV fluid therapy in adults in hospital', to provide insight on the learning needs and expectations of physicians and nurses. Each survey focused on profession-specific practice and consisted of three parts: demographics, knowledge questions and evaluation of current habits. Physicians and nurses practicing in a Belgian university hospital were invited to complete the survey electronically, respectively, in January and May 2018.

RESULTS

A total of 103 physicians (19%) and 259 nurses (24%) participated. Although every indication for fluid therapy may require a specific fluid and electrolyte mixture, and hence, knowledge of their exact composition, most physicians and nurses did not know the composition of commonly prescribed solutions for IV infusion. Senior physicians did not score better than juniors did on questions concerning the daily needs of a nil-by-mouth patient. The availability of an IV fluid on the ward guides physicians to prescribe IV fluids (17%). Nurses (56%) feel they share responsibility in fluid management as they frequently intervene in urgent situations. More than half of participants (70% of physicians, 79% of nurses) indicated a need for additional information.

CONCLUSIONS

A clear need for more structured information on IV fluids was identified. Both physicians and nurses struggle with fluid therapy. Continuing education on IV fluid management, emphasizing multidisciplinary collaboration, and monitoring evidence-based practice is essential to support the clinical decision process in daily practice.

Advantages in Management and Remote Monitoring of Intravenous Therapy: Exploratory Survey and Economic Evaluation of Gravity-Based Infusions in Finland

INTRODUCTION

Intravenous infusion therapy is a common and challenging invasive treatment procedure in hospital wards. Administration mistakes can have serious, even life-threatening, consequences. The Monidor solution was developed to help nurses administer gravity-based infusions and monitor them remotely, to avoid complications and reduce workload. Its real-world effects and economic consequences were unknown.

METHODS

An exploratory survey was carried out to estimate the potential impact of the Monidor solution on events and nurse time use. At the end of their shift, nurses estimated effects in terms of routine room visits avoided, prevention of complications, and impact on nurse time requirements. Linear regression was applied to estimate predictors of time freed. A health economic model was developed to evaluate economic consequences and to calculate the net return on investment for a hypothetical hospital ward. A 1-month time horizon was used, and discounting was not applied.

RESULTS

A total of 216 responses were obtained from 6 Finnish hospitals, from a total of 15 wards, and 56.3% of nurses found that the Monidor solution freed nurse time, while < 3.5% experienced additional time requirements. Per nurse shift, the Monidor solution avoided on average 2.064 routine room visits, helped detect end of infusion 1.340 times, and led to 5.045 min of time freed. One routine visit avoided was associated with 2.453 min of time freed in the linear regression. In the conservative setting, the freed monthly capacity in the hypothetical ward amounted to €1270.90 per month (year 2021), yielding a return on investment of 2.63. Uncertainty of linear regression coefficient values was identified as a driver of uncertainty in sensitivity analysis, with return on investment ranging from 1.55 to 3.71.

CONCLUSIONS

The study demonstrated that management and remote monitoring with the Monidor solution frees nurse time and reduces routine activities associated with gravity-based intravenous infusions. These findings could be confirmed in a comparative empirical study.

Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions

AIMS

Accurate documentation of medication administration time is imperative for many therapeutic decisions, including dosing of intravenous antimicrobials. The objectives were to determine (1) the discrepancy between actual and documented administration times for antimicrobial infusions and (2) whether day of the week, time of day, nurse-to-patient ratio and drug impacted accuracy of documented administration times.

METHODS

Patient and dosing data were collected (June-August 2019) for 55 in-patients receiving antimicrobial infusions. "Documented" and "actual" administration times (n = 660) extracted from electronic medication management systems and smart infusion pumps, respectively, were compared. Influence of the day (weekday/weekend), time of day (day/evening/night), nurse-to-patient ratio (high 1:1/low 1:5) and drug were examined. Monte Carlo simulation was used to predict the impact on dose adjustments for vancomycin using the observed administration time discrepancies compared to the actual administration time.

RESULTS

The median discrepancy between actual and documented administration times was 16 min (range, 2-293 min), with discrepancies greater than 60 minutes in 7.7% of administrations. Overall, discrepancies (median [range]) were similar on weekends (17 [2-293] min) and weekdays (16 [2-188] min), and for high (16 [2-157] min) and low nurse-to-patient ratio wards (16 [2-293] min). Discrepancies were smallest for night administrations (P < .05), and antimicrobials with shorter half-lives (P < .0001). The observed discrepancies in vancomycin administration time resulted in a different dose recommendation in 58% of cases (30% higher, 28% lower).

CONCLUSIONS

Overall, there were discrepancies between actual and documented antimicrobial infusion administration times. For vancomycin, these discrepancies in administration time were predicted to result in inappropriate dose recommendations.

Using automated pump-delivery devices to reduce the incidence of excessive fluid administration during pediatric dental surgery: a randomized-controlled trial

PURPOSE

The harms caused by excessive perioperative intravenous (IV) fluid administration are both well recognized and avoidable. The purpose of this study was to compare the incidence of excess intraoperative fluid administration in pediatric dental surgery patients when either an automated pump-delivery device or a manual gravity-drip device is used.

METHODS

We randomly assigned American Society of Anesthesiologists physical status I and II pediatric dental surgery patients to receive IV fluid via either a manual gravity-drip or automated pump-delivery device. Prior to each case, the attending anesthesiologist determined the target volume of maintenance IV fluid to be administered based on patient weight, estimated fluid deficits, and expected case length. The intraoperative IV fluid delivered was determined at the end of the case by the change in the IV bag weight. The primary outcome was the proportion of procedures that delivered ≥ 10% of the target IV fluid volume.

RESULTS

We recruited 105 children aged two to 12 yr (n = 49 in the automated pump-delivery device; n = 53 in the manual gravity-drip device). The proportion of excessive fluid administration was 8/49 (16%) in the automated pump-delivery device group compared with 33/53 (62%) in the gravity-drip group (relative risk of excessive fluid administration, 0.26; 95% confidence interval, 0.13 to 0.51; P < 0.001).

CONCLUSION

Intraoperative fluid administration using an automated pump-delivery device decreased the incidence of excessive IV fluid administration in pediatric dental surgery patients.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03312452); registered 17 October 2017.

Diagnosis and Management of Acute Heart Failure in Sub-Saharan Africa

PURPOSE OF REVIEW

Acute heart failure (AHF) is a common emergency presentation in Sub-Saharan Africa (SSA). In the current review, we present the most recent data on the epidemiology of AHF in SSA and discuss recommended approaches to management in resource-limited settings, with a particular focus on primary and secondary facilities (e.g., health centers and district hospitals), where these patients often present.

RECENT FINDINGS

AHF in SSA is most often due to hypertension, cardiomyopathies, and rheumatic heart disease. The etiology of AHF may be different in rural as compared with urban settings. Diagnostic tools for AHF are often lacking in SSA, especially at the first-level facilities. Point-of-care ultrasound (POCUS) and biomarker tests, such as brain natriuretic peptide (BNP), offer promise in helping to mitigate diagnostic challenges. POCUS can also help distinguish among types of heart failure and prompt the correct treatment strategy. Many of the drugs and equipment commonly used to treat AHF in resource-rich settings are lacking in SSA. However, some adaptations of commonly available materials may provide temporary alternatives. The epidemiology of AHF in SSA differs from that of high-income settings. Management of AHF at the first-level facility in SSA is an important and understudied problem. Simplified diagnostic and treatment algorithms rooted in knowledge of the local epidemiology should be developed and tested as part of broader efforts to combat cardiovascular disease in SSA.

Development of an Al-load-cell-based wireless ringer's solution monitoring and alarm system: insight into vibrational error correction

In this study, we developed an aluminum-load-cell-based wireless Ringer's solution monitoring and alarm (WRMA) system. The Al load cell was designed with a rectangular shape, and the load was concentrated in the lower beam part of the load cell because of the anisotropic thickness. From the static analysis, we identified the appropriate location for a Wheatstone bridge circuit consisting of four strain gauges. In addition, the modal and harmonic analyses showed that the vibrational frequencies of the hospital environment do not seriously interfere with the output voltage of the Al load cell. However, random vibrations generated by the movement of the WRMA system on various surfaces severely increase the standard deviation of the measured solution weight by ± 10 g or more. Such vibrational error is too large because the average weight of Ringer's solution is 30-40 g at the time of replacing Ringer's solution. Thus, this error could be confusing for nurses and result in mistakes in the timely replacement of the Ringer's solution. However, the standard deviation of the measured weight was dramatically reduced to ± 3 g or less by using the vibration correction algorithm developed in the present study.

IV DripAssist: An Innovative Way to Monitor Intravenous Infusions Away From an Outlet?

Intravenous (IV) administration of fluids and medications are a significant part of patient treatment. In austere environments, typical methods of counting drops from gravity drips or infusion pumps both have limitations such as accuracy, weight, and need for power. The DripAssist device calculates drip rates by counting drops in IV tubing drip chambers and may provide a useful patient safety monitor adjunct. The protocol was IRB approved, prospective, and designed as a pilot study involving 28 Madigan Army Medical Center Emergency Department personnel. After a brief didactic introduction to the device for clinical staff with no prior experience using the device, participants were timed setting three normal saline infusions at rates of 250 mL/h, 125 mL/h and 83 mL/h with 15gtt/mL tubing. Participants filled out a survey on perceived ease of use and utility of the device compared to pumps and manual counting. Most participants felt the DripAssist device was easy to understand and set up, but nurses and physician assistants were more likely than medics to perceive a benefit versus IV pumps or gravity drips. The DripAssist device may offer a safe, low-weight, functional tool which could improve care in a variety of resource-limited environments. However, additional studies using the device during actual field exercises would be beneficial.

Intravenous Fluid Challenge Decreases Intracellular Volume: A Bioimpedance Spectroscopy-Based Crossover Study in Healthy Volunteers

The effects of intravenous fluid therapy on fluid compartments and hemodynamics of the human body remain enigmatic. We therefore tested the efficacy of bioimpedance spectroscopy in a crossover study, where 15 males received 0.5 ml/kg/min ELO-MEL-isoton (osmolarity = 302 mosmol/l) during 60 minutes, or nothing at all. In group “Fluid”, fluid load increased from −0.2 ± 1.0 l extracellular volume at baseline to its maximum of 1.0 ± 0.9 l in minute 70, and remained continuously elevated throughout minute 300. In group “Zero”, fluid load decreased from 0.5 ± 1.1 l at baseline to its minimum of −1.1 ± 1.1 l in minute 300. In group “Fluid”, intracellular volume decreased from 26.8 ± 3.9 l at baseline to its minimum of 26.0 ± 3.9 l in minute 70, and remained continuously decreased throughout minute 300. In group “Zero”, intracellular volume increased from 26.5 ± 3.8 l at baseline to its maximum of 27.1 ± 3.9 l in minute 120, and decreased thereafter. In group “Fluid” compared to “Zero”, systolic blood pressure was significantly higher, from minute 50–90. In conclusion, intravenous fluid therapy caused a clinically meaningful, sustained increase in fluid load, and a decrease in intracellular volume. These data raise interest in studying fluid administration by the gastrointestinal route, perhaps even when managing critical illness.

How Do Simulated Error Experiences Impact Attitudes Related to Error Prevention?

INTRODUCTION

The objective of this project was to determine whether simulated exposure to error situations changes attitudes in a way that may have a positive impact on error prevention behaviors.

METHODS

Using a stratified quasi-randomized experiment design, we compared risk perception attitudes of a control group of nursing students who received standard error education (reviewed medication error content and watched movies about error experiences) to an experimental group of students who reviewed medication error content and participated in simulated error experiences. Dependent measures included perceived memorability of the educational experience, perceived frequency of errors, and perceived caution with respect to preventing errors.

RESULTS

Experienced nursing students perceived the simulated error experiences to be more memorable than movies. Less experienced students perceived both simulated error experiences and movies to be highly memorable. After the intervention, compared with movie participants, simulation participants believed errors occurred more frequently. Both types of education increased the participants' intentions to be more cautious and reported caution remained higher than baseline for medication errors 6 months after the intervention.

CONCLUSIONS

This study provides limited evidence of an advantage of simulation over watching movies describing actual errors with respect to manipulating attitudes related to error prevention. Both interventions resulted in long-term impacts on perceived caution in medication administration. Simulated error experiences made participants more aware of how easily errors can occur, and the movie education made participants more aware of the devastating consequences of errors.

Medication errors in chemotherapy preparation and administration: a survey conducted among oncology nurses in Turkey

BACKGROUND

Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience.

MATERIALS AND METHODS

This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data.

RESULTS

Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%).

CONCLUSIONS

Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

INTERACTION BETWEEN OBJECTIVE PERFORMANCE MEASURES AND SUBJECTIVE USER PERCEPTIONS IN THE EVALUATION OF MEDICAL DEVICES: A CASE STUDY

OBJECTIVES

Medical technology is a large and expanding industry. Introducing new medical devices is important but several challenges exist in implementing the optimal method of evaluation. Both objective and subjective measures can be used for evaluation. The former is the mainstay of evaluation, yet subjective assessment is often the basis for the introduction of new medical technology. The aim of this study was to determine the interaction and concordance between objective and subjective assessment of new medical technology.

METHODS

This study used both objective performance measures and subjective user perceptions in the evaluation of a new medical device designed to improve the accuracy of gravity-assisted delivery of intravenous fluids, compared with the current, widely used "roller-clamp" device. The concordance of objective and subjective assessments was evaluated using comparative analysis.

RESULTS

Objective assessment of the accuracy of intravenous fluid delivery revealed no difference between the two devices (p = .636). Subjective assessment revealed that the new device was perceived to be significantly more accurate (p = .001). This lack of concordance can be partially explained by both device and demand characteristics.

CONCLUSIONS

This case study reveals a significant discordance between the objective and subjective assessments. It provides some explanation for why new medical devices are adopted without objective evidence of benefit. This phenomenon has been termed "persuasive design" and its influence should be controlled for in the evaluation, purchase and introduction of new medical devices. This should help reduce the risk and associated cost of premature introduction.

Aseptic preparation of parenteral medicinal products in healthcare establishments in Europe

In many cases, parenteral medicines with a marketing authorisation cannot be administered directly to patients, that is, they are not presented in ready-to-administer form. Before administration to patients, these medicines have to be reconstituted. Reconstitution has a special position; it can neither be seen as industrial manufacture nor as 'regular' pharmacy preparation. There are other processes in healthcare establishments (eg, parenteral nutrition), related to the reconstitution process, where the requirements of national quality assurance standards for the safe preparation of sterile products are equally important and have to be fulfilled. In European healthcare establishments, aseptic preparation of parenteral medicinal products is considered to be a process of crucial importance for patient safety because errors in the preparation of these medicines may lead to a product that can cause immediate damage to patients. Aseptic preparation of medicinal products is carried out in hospital pharmacies as well as in clinical areas in healthcare establishments. The Committee of Experts on Quality and Safety Standards for Pharmaceutical Practices and Pharmaceutical Care (Council of Europe; hereafter: Committee of Experts), supported by the European Directorate for the Quality of Medicines & Healthcare, is undertaking work on the topic of aseptic preparation of medicines. The work is carried out in cooperation with the European Association of Hospital Pharmacists on the basis of a Resolution CM/Res AP(2011)1 on Quality and Safety Assurance requirements for Medicinal Products prepared in Pharmacies for the Special Needs of Patients, which was adopted by the Committee of Ministers on 19 January 2011. The Resolution includes some recommendations and an outlook to further work on reconstitution of parenteral medicines. A survey that was sent to the different European countries demonstrated that there is no or just limited regulation concerning reconstitution in Europe. This article describes the risks associated with poor reconstitution practices and the previous work as well as the ongoing activities concerning reconstitution at the European level. The article emphasises the need for regulation in this area, which is missing at present. It is expected that consensus can be reached on a guidance document for reconstitution at the European level.

[Responsibility due to medication errors in France: a study based on SHAM insurance data]

PURPOSE

The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications.

METHODS

The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010).

RESULTS

Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy.

CONCLUSION

The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management.

The Rate of Physicochemical Incompatibilities, Administration Errors. Factors Correlating with Nurses' Errors

Medication errors are commonly encountered in hospital setting. Intravenous medications pose particular risks because of their greater complexity and the multiple steps required in their preparation, administration and monitoring. We aimed to determine the rate of errors during the preparation and administration phase of intravenous medications and the correlation of these errors with the demographics of nurses involved in the process. One hundred patients who were receiving IV medications were monitored by a trained pharmacist. The researcher accompanied the nurses during the preparation and administration process of IV medications. Collected data were compared with the acceptable guidelines. A checklist was filled for each IV medication. Demographic data of the nurses were collected as well. A total of 454 IV medications were recorded. Inappropriate administration rate constituted a large proportion of errors in our study (35.3%). No significant or life threatening drug interaction was recorded during the study. Evaluating the impact of the nurses' demographic characteristics on the incidence of medication errors showed that there is a direct correlation between nurses' employment status and the rate of medication errors, while other characteristics did not show a significant impact on the rate of administration errors. Administration errors were significantly higher in temporary 1-year contract group than other groups (p-value < 0.0001). Study results show that there should be more vigilance on administration rate of IV medications to prevent negative consequences especially by pharmacists. Optimizing the working conditions of nurses may play a crucial role.

Incidence of intravenous drug incompatibilities in intensive care units

AIMS

Drug incompatibilities are relatively common in inpatients and this may result in increased morbidity/mortality as well as add to costs. The aim of this 12 month study was to identify real incidences of drug incompatibilities in intravenous lines in critically ill patients in two intensive care units (ICUs).

METHODS

A prospective cross sectional study of 82 patients in 2 ICUs, one medical and one surgical in a 1500-bed university hospital. One monitor carried out observations during busy hours with frequent drug administration. Patients included in both ICUs were those receiving at least two different intravenous drugs.

RESULTS

6.82% and 2.16% of drug pairs were found to be incompatible in the two ICUs respectively. Among the most frequent incompatible drugs found were insulin, ranitidine and furosemide.

CONCLUSIONS

The study showed that a significant number of drug incompatibilities occur in both medical and surgical ICUs. It follows that the incidence of incompatibilities could be diminished by adhering to a few simple rules for medication administration, following by recommendations for multiple lumen catheter use. Future prospective studies should demonstrate the effect of applying these policies in practice.

Estimated cost savings from reducing errors in the preparation of sterile doses of medications

BACKGROUND

Preventing intravenous (IV) preparation errors will improve patient safety and reduce costs by an unknown amount.

OBJECTIVE

To estimate the financial benefit of robotic preparation of sterile medication doses compared to traditional manual preparation techniques.

METHODS

A probability pathway model based on published rates of errors in the preparation of sterile doses of medications was developed. Literature reports of adverse events were used to project the array of medical outcomes that might result from these errors. These parameters were used as inputs to a customized simulation model that generated a distribution of possible outcomes, their probability, and associated costs.

RESULTS

By varying the important parameters across ranges found in published studies, the simulation model produced a range of outcomes for all likely possibilities. Thus it provided a reliable projection of the errors avoided and the cost savings of an automated sterile preparation technology. The average of 1,000 simulations resulted in the prevention of 5,420 medication errors and associated savings of $288,350 per year. The simulation results can be narrowed to specific scenarios by fixing model parameters that are known and allowing the unknown parameters to range across values found in previously published studies.

CONCLUSIONS

The use of a robotic device can reduce health care costs by preventing errors that can cause adverse drug events.

Improving surgical intravenous fluid management: a controlled educational study

BACKGROUND

This study aims to measure whether the introduction of a multifaceted, evidence-based, educational intervention will improve both intravenous (i.v.) fluids prescribed by doctors and administrated by nurses.

METHODS

A daily baseline audit of i.v. fluid prescription and administration for colorectal inpatients was carried out at two Auckland teaching hospitals over 4 weeks. The educational intervention was then administered at hospital 1, while at hospital 2 nurses and junior doctors were merely informed of the audit. The educational intervention included a lecture, multiple posters around the wards and pocket i.v. fluid protocols for junior doctors. Data collection continued for a further 4 weeks at both sites.

RESULTS

The study included 513 days of i.v. fluids received by 109 patients at the two sites. At hospital 1 following the intervention, there was an improvement in the number of correct prescriptions of maintenance i.v. fluids from 21% to 62% (P < 0.001). There were also improvements in the number of patients who received correct administration of i.v. maintenance fluids from 26% to 57% (P < 0.001), gastric loss i.v. replacement from 61% to 93% (P < 0.001) and bowel loss i.v. replacement fluids from 59% to 85% (P = 0.004). None of these measures improved at hospital 2.

CONCLUSION

At baseline, both prescription and administration of i.v. fluids were poor. A multifaceted educational intervention, involving teaching sessions with handouts, pocket-sized cards and posters visible on the wards, has brought improvements to both the prescription and administration of i.v. fluids in patients managed by colorectal surgeons.

Drug administration errors in hospital inpatients: a systematic review

CONTEXT

Drug administration in the hospital setting is the last barrier before a possible error reaches the patient.

OBJECTIVES

We aimed to analyze the prevalence and nature of administration error rate detected by the observation method.

DATA SOURCES

Embase, MEDLINE, Cochrane Library from 1966 to December 2011 and reference lists of included studies.

STUDY SELECTION

Observational studies, cross-sectional studies, before-and-after studies, and randomized controlled trials that measured the rate of administration errors in inpatients were included.

DATA EXTRACTION

Two reviewers (senior pharmacists) independently identified studies for inclusion. One reviewer extracted the data; the second reviewer checked the data. The main outcome was the error rate calculated as being the number of errors without wrong time errors divided by the Total Opportunity for Errors (TOE, sum of the total number of doses ordered plus the unordered doses given), and multiplied by 100. For studies that reported it, clinical impact was reclassified into four categories from fatal to minor or no impact. Due to a large heterogeneity, results were expressed as median values (interquartile range, IQR), according to their study design.

RESULTS

Among 2088 studies, a total of 52 reported TOE. Most of the studies were cross-sectional studies (N=46). The median error rate without wrong time errors for the cross-sectional studies using TOE was 10.5% [IQR: 7.3%-21.7%]. No fatal error was observed and most errors were classified as minor in the 18 studies in which clinical impact was analyzed. We did not find any evidence of publication bias.

CONCLUSIONS

Administration errors are frequent among inpatients. The median error rate without wrong time errors for the cross-sectional studies using TOE was about 10%. A standardization of administration error rate using the same denominator (TOE), numerator and types of errors is essential for further publications.

Drip Adjuster: Use of an LED Display to Manually Adjust Intravenous Fluid Infusion Rate

Errors in intravenous infusion rates are common at hospitals. A previous study found that actual infusion rates differ significantly from those instructed by doctors. The technique used to adjust the drip rate using a watch is a difficult skill to learn. In this article, we present our recently developed drip adjuster, which makes it easier for a nurse, for example, to adjust the drip rate using an LED display controlled by an Arduino microcontroller. We analyzed a high-speed video of falling infusion drops and imitated dripping by changing the brightness and positioning of light displayed by a row of five LEDs, enabling nurses to easily synchronize LED lighting with the growth and falling of droplets. We then evaluated the accuracy of the drip rate when six nurses used the drip adjuster versus using a watch. We found a significant difference in accuracy between the two methods, with a dramatic increase from 40% accuracy using a watch to 83% accuracy using the drip adjuster in the achievement of an accurate drip rate. The drip adjuster is a simple, effective device that can be used to assist in adjusting the drip rates of intravenous infusions.

Avoidable interruptions during drug administration in an intensive rehabilitation ward: improvement project

AIMS

To record the frequency of interruptions and their causes, to identify 'avoidable' interruptions and to build an improvement project to reduce 'avoidable' interruptions.

BACKGROUND

In Italy each year 30,000-35,000 deaths per year are attributed to health-care system errors, of which 19% are caused by medication errors. The factors that contribute to drug management error also include interruptions and carelessness during treatment administration.

METHODS

A descriptive study design was used to record the frequency of interruptions and their causes and to identify 'avoidable' interruptions in an intensive rehabilitation ward in Northern Italy. A data collection grid was used to record the data over a 6-month period.

RESULTS

A total of 3000 work hours were observed. During the study period 1170 interruptions were observed. The study identified 14 causes of interruption.

CONCLUSIONS

The study shows that of the 14 cases of interruptions at least nine can be defined as 'avoidable'. An improvement project has been proposed to reduce unnecessary interruptions and distractions to avoid making errors.

IMPLICATIONS FOR NURSING MANAGEMENT

An additional useful step to reduce the incidence of treatment errors would be to implement the use of a single patient medication sheet for the recording of drug prescription, preparation and administration and also the incident reporting.

Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience

Background

Intravenous medication administrations have a high incidence of error but there is limited evidence of associated factors or error severity.

Objective

To measure the frequency, type and severity of intravenous administration errors in hospitals and the associations between errors, procedural failures and nurse experience.

Methods

Prospective observational study of 107 nurses preparing and administering 568 intravenous medications on six wards across two teaching hospitals. Procedural failures (eg, checking patient identification) and clinical intravenous errors (eg, wrong intravenous administration rate) were identified and categorised by severity.

Results

Of 568 intravenous administrations, 69.7% (n=396; 95% CI 65.9 to 73.5) had at least one clinical error and 25.5% (95% CI 21.2 to 29.8) of these were serious. Four error types (wrong intravenous rate, mixture, volume, and drug incompatibility) accounted for 91.7% of errors. Wrong rate was the most frequent and accounted for 95 of 101 serious errors. Error rates and severity decreased with clinical experience. Each year of experience, up to 6 years, reduced the risk of error by 10.9% and serious error by 18.5%. Administration by bolus was associated with a 312% increased risk of error. Patient identification was only checked in 47.9% of administrations but was associated with a 56% reduction in intravenous error risk.

Conclusions

Intravenous administrations have a higher risk and severity of error than other medication administrations. A significant proportion of errors suggest skill and knowledge deficiencies, with errors and severity reducing as clinical experience increases. A proportion of errors are also associated with routine violations which are likely to be learnt workplace behaviours. Both areas suggest specific targets for intervention.

Preparation of parenteral medicines in clinical areas: how can the risks be managed - a UK perspective?

AIMS AND OBJECTIVES

This article provides an overview of preparation of parenteral medicines in clinical areas. It describes the development of a tool to allow preparation of these medicines to be scored for risk. The article shows how this work was adopted by the National Patient Safety Agency (NPSA) and was subsequently issued as Patient Safety Alert 20 (Injectable Medicines).

BACKGROUND

Although there are well-established standards for preparation of parenteral medicines in pharmacy, there were no equivalent standards for their preparation in clinical areas, where risks to patients from medication error and microbiological contamination are greater. Use of a risk assessment process allows highest risk items to be targeted for transfer to pharmacy preparation. Defined standards and competency-based training should reduce risk for preparation of those items remaining in clinical areas.

METHOD

Discursive.

CONCLUSIONS

This article identifies the risks involved in the preparation of parenteral medicines in clinical areas and describes ways in which these risks can be minimised.

RELEVANCE TO CLINICAL PRACTICE

Use of risk assessment allows targeted transfer of high-risk parenteral medicines to pharmacy preparation, where risks of medication error and microbiological contamination are lower. This transfer liberates nursing time for patient benefit.

The epidemiology of medication errors: the methodological difficulties

1. Medication errors should be amenable to epidemiological analysis, giving insights into the causes of error and the effects of interventions to prevent them or reduce harm from them. 2. There are formidable difficulties in establishing the rates of medication errors. 3. There is no agreement on a clear operational definition of the condition. 4. The methods used to enumerate cases so far have been unreliable or incomplete or both. 5. There is disagreement about whether cases of error that do not cause harm should be included in calculations of error rates. 6. When harm occurs in association with drug therapy, it is often unclear whether the harm might have been prevented, and its occurrence should therefore be considered to result from error. 7. The denominator for calculating the rate of error is both ill-defined and inconsistently measured. Better definitions, more complete evaluation, and more thorough impact assessment may improve matters.

The pathophysiology of medication errors: how and where they arise

1. Errors arise when an action is intended but not performed; errors that arise from poor planning or inadequate knowledge are characterized as mistakes; those that arise from imperfect execution of well-formulated plans are called slips when an erroneous act is committed and lapses when a correct act is omitted. 2. Some tasks are intrinsically prone to error. Examples are tasks that are unfamiliar to the operator or performed under pressure. Tasks that require the calculation of a dosage or dilution are especially susceptible to error. 3. The tasks of prescribing, preparation, and administration of medicines are complex, and are carried out within a complex system; errors can occur at each of many steps and the error rate for the overall process is therefore high. 4. The error rate increases when health-care professionals are inexperienced, inattentive, rushed, distracted, fatigued, or depressed; orthopaedic surgeons and nurses may be more likely than other health-care professionals to make medication errors. 5. Medication error rates in hospital are higher in paediatric departments and intensive care units than elsewhere. 6. Rates of medication errors may be higher in very young or very old patients. 7. Intravenous antibiotics are the drugs most commonly involved in medication errors in hospital; antiplatelet agents, diuretics, and non-steroidal anti-inflammatory drugs are most likely to account for 'preventable admissions'. 8. Computers effectively reduce the rates of easily counted errors. It is not clear whether they can save lives lost through rare but dangerous errors in the medication process.

Do calculation errors by nurses cause medication errors in clinical practice? A literature review

This review aims to examine the literature available to ascertain whether medication errors in clinical practice are the result of nurses' miscalculating drug dosages. The research studies highlighting poor calculation skills of nurses and student nurses have been tested using written drug calculation tests in formal classroom settings [Kapborg, I., 1994. Calculation and administration of drug dosage by Swedish nurses, student nurses and physicians. International Journal for Quality in Health Care 6(4): 389 -395; Hutton, M., 1998. Nursing Mathematics: the importance of application Nursing Standard 13(11): 35-38; Weeks, K., Lynne, P., Torrance, C., 2000. Written drug dosage errors made by students: the threat to clinical effectiveness and the need for a new approach. Clinical Effectiveness in Nursing 4, 20-29]; Wright, K., 2004. Investigation to find strategies to improve student nurses' maths skills. British Journal Nursing 13(21) 1280-1287; Wright, K., 2005. An exploration into the most effective way to teach drug calculation skills to nursing students. Nurse Education Today 25, 430-436], but there have been no reviews of the literature on medication errors in practice that specifically look to see whether the medication errors are caused by nurses' poor calculation skills. The databases Medline, CINAHL, British Nursing Index (BNI), Journal of American Medical Association (JAMA) and Archives and Cochrane reviews were searched for research studies or systematic reviews which reported on the incidence or causes of drug errors in clinical practice. In total 33 articles met the criteria for this review. There were no studies that examined nurses' drug calculation errors in practice. As a result studies and systematic reviews that investigated the types and causes of drug errors were examined to establish whether miscalculations by nurses were the causes of errors. The review found insufficient evidence to suggest that medication errors are caused by nurses' poor calculation skills. Of the 33 studies reviewed only five articles specifically recorded information relating to calculation errors and only two of these detected errors using the direct observational approach. The literature suggests that there are other more pressing aspects of nurses' preparation and administration of medications which are contributing to medication errors in practice that require more urgent attention and calls into question the current focus on calculation and numeracy skills of pre registration and qualified nurses (NMC 2008). However, more research is required into the calculation errors in practice. In particular there is a need for a direct observational study on paediatric nurses as there are presently none examining this area of practice.

A literature review of the individual and systems factors that contribute to medication errors in nursing practice

AIM

This paper reports a review of the empirical literature on factors that contribute to medication errors.

BACKGROUND

Medication errors are a significant cause of morbidity and mortality in hospitalized patients. This creates an imperative to reduce medication errors to deliver safe and ethical care to patients.

METHOD

The databases CINAHL, PubMed, Science Direct and Synergy were searched from 1988 to 2007 using the keywords medication errors, medication management, medication reconciliation, medication knowledge and mathematical skills, and reporting medication errors. RESULTS Contributory factors to nursing medication errors are manifold, and include both individual and systems issues. These include medication reconciliation, the types of drug distribution system, the quality of prescriptions, and deviation from procedures including distractions during administration, excessive workloads, and nurse's knowledge of medications.

IMPLICATIONS FOR NURSING MANAGEMENT

It is imperative that managers implement strategies to reduce medication errors including the establishment of reporting mechanisms at international and national levels to include the evaluation and audit of practice at a local level. Systematic approaches to medication reconciliation can also reduce medication error significantly. Promoting consistency between health care professionals as to what constitutes medication error will contribute to increased accuracy and compliance in reporting of medication errors, thereby informing health care policies aimed at reducing the occurrence of medication errors. Acquisition and maintenance of mathematical competency for nurses in practice is an important issue in the prevention of medication error. The health care industry can benefit from learning from other high-risk industries such as aviation in the prevention and management of systems errors.

Review of patient safety incidents submitted from Critical Care Units in England & Wales to the UK National Patient Safety Agency

We reviewed and classified all patient safety incidents submitted from critical care units in England and Wales to the National Patient Safety Agency for the first quarter of 2008. A total of 6649 incidents were submitted from 141 organisations (median (range) 23 (1-268 incidents)); 786 were unrelated to the critical care episode and 248 were repeat entries. Of the remaining 5615 incidents, 1726 occurred in neonates or babies, 1298 were associated with temporary harm, 15 with permanent harm and 59 required interventions to maintain life or may have contributed to the patient's death. The most common main incident groups were medication (1450 incidents), infrastructure and staffing (1289 incidents) and implementation of care (1047 incidents). There were 2789 incidents classified to more than one main group. The incident analysis highlights ways to improve patient safety and to improve the classification of incidents.

Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008

BACKGROUND

This paper presents Part 1 of a two-part literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care to update a previous national report on medication safety conducted in 2002. This first part of the review examines the extent and causes of medication incidents and adverse drug events in acute care.

METHODS

A literature search was conducted to identify Australian studies, published from 2002 to 2008, on the extent and causes of medication incidents and adverse drug events in acute care.

RESULTS

Studies published since 2002 continue to suggest approximately 2%-3% of Australian hospital admissions are medication-related. Results of incident reporting from hospitals show that incidents associated with medication remain the second most common type of incident after falls. Omission or overdose of medication is the most frequent type of medication incident reported. Studies conducted on prescribing of renally excreted medications suggest that there are high rates of prescribing errors in patients requiring monitoring and medication dose adjustment. Research published since 2002 provides a much stronger Australian research base about the factors contributing to medication errors. Team, task, environmental, individual and patient factors have all been found to contribute to error.

CONCLUSION

Medication-related hospital admissions remain a significant problem in the Australian healthcare system. It can be estimated that 190,000 medication-related hospital admissions occur per year in Australia, with estimated costs of $660 million. Medication incidents remain the second most common type of incident reported in Australian hospitals. A number of different systems factors contribute to the occurrence of medication errors in the Australian setting.

Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008

Background

This paper presents Part 1 of a two-part literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care to update a previous national report on medication safety conducted in 2002. This first part of the review examines the extent and causes of medication incidents and adverse drug events in acute care.

Methods

A literature search was conducted to identify Australian studies, published from 2002 to 2008, on the extent and causes of medication incidents and adverse drug events in acute care.

Results

Studies published since 2002 continue to suggest approximately 2%–3% of Australian hospital admissions are medication-related. Results of incident reporting from hospitals show that incidents associated with medication remain the second most common type of incident after falls. Omission or overdose of medication is the most frequent type of medication incident reported. Studies conducted on prescribing of renally excreted medications suggest that there are high rates of prescribing errors in patients requiring monitoring and medication dose adjustment. Research published since 2002 provides a much stronger Australian research base about the factors contributing to medication errors. Team, task, environmental, individual and patient factors have all been found to contribute to error.

Conclusion

Medication-related hospital admissions remain a significant problem in the Australian healthcare system. It can be estimated that 190,000 medication-related hospital admissions occur per year in Australia, with estimated costs of $660 million. Medication incidents remain the second most common type of incident reported in Australian hospitals. A number of different systems factors contribute to the occurrence of medication errors in the Australian setting.

The assessment and development of drug calculation skills in nurse education--a critical debate

The drug calculation skill of nurses continues to be a national concern. The continued concern has led to the introduction of mandatory drug calculation skills tests which students must pass in order to go on to the nursing register. However, there is little evidence to demonstrate that nurses are poor at solving drug calculation in practice. This paper argues that nurse educationalists have inadvertently created a problem that arguably does not exist in practice through use of invalid written drug assessment tests and have introduced their own pedagogical practice of solving written drug calculations. This paper will draw on literature across mathematics, philosophy, psychology and nurse education to demonstrate why written drug assessments are invalid, why learning must take place predominantly in the clinical area and why the key focus on numeracy and formal mathematical skills as essential knowledge for nurses is potentially unnecessary.

The determination of record-keeping behavior of nurses regarding intravenous fluid treatment: the case of Turkey

Record-keeping is one of the legal and professional responsibilities of nurses. This study aims to determine the record-keeping behavior of nurses regarding intravenous fluid treatment (IVFT). The study was conducted with 150 nurses working in adult clinics of a 936-bed university hospital. The most frequently fulfilled record-keeping behaviors were solution type, total solution amount, and date of treatment. The least frequent fulfilled behaviors were the diagnosis of patients and the time of passage of medication added to the solution. The nurses never recorded type of i.v. fluid treatment, complications, and discontinuation of therapy. According to findings of the study, the record-keeping behavior of nurses regarding IVFT is not at the desired level.

Accuflow an infusion rate monitor: an evaluation in pediatric patients

OBJECTIVE

To evaluate the accuracy of ACCUFLOW an infusion rate monitor as compared to manual reading in pediatric surgical patients.

METHODS

An observational study in 47 pediatric patients undergoing elective surgical procedures and needing an intravenous fluid with expected duration of infusion of at least one hour. The infusion rate was adjusted to the required flow rate with the help of the display on the ACCUFLOW. The flow rate as indicated by the ACCUFLOW display was checked every 15 minutes till the end of one hour. A simultaneous record of manual readings was also made.

RESULTS

A total of 470 observations were made over the one hour observation period. The infusion rate as observed on the LCD display of the ACCUFLOW compared well with manual reading. A Bland Altman analysis showed the bias between the readings with the two methods to be very small and that there is no significant difference between the methods over the drop rate of 61-74 drops/min. In addition an alarm was heard in 9 cases. The alarm was mainly because of no flow or excess flow (3 cases each). Other causes for the alarm included slow flow, faulty i.v. lines showing fluctuations in flow rate and drip chamber not placed properly (1 patient each).

CONCLUSION

ACCUFLOW is a low cost device that can be used to adjust and monitor the infusion flow rate. The alarm would alert the nursing staff when there is deviation from the preset rate of infusion. ACCUFLOW could thus be an attractive option for infusion rate monitoring in developing countries with limited healthcare resources and skewed patient nurse ratios. However applicability to infants and younger children and for longer infusions needs to be determined.

Errors in the administration of intravenous medication in Brazilian hospitals

AIM

To verify the frequency of errors in the preparation and administration of intravenous medication in three Brazilian hospitals in the State of Bahia.

BACKGROUND

The administration of intravenous medications constitutes a central activity in Brazilian nursing. Errors in performing this activity may result in irreparable damage to patients and may compromise the quality of care.

DESIGN

Cross-sectional study, conducted in three hospitals in the State of Bahia, Brazil.

METHODS

Direct observation of the nursing staff (nurse technicians, auxiliary nurses and nurse attendants), preparing and administering intravenous medication.

RESULTS

When preparing medication, wrong patient error did not occur in any of the three hospitals, whereas omission dose was the most frequent error in all study sites. When administering medication, the most frequent errors in the three hospitals were wrong dose and omission dose.

CONCLUSIONS

The rates of error found are considered low compared with similar studies. The most frequent types of errors were wrong dose and omission dose. The hospitals studied showed different results with the smallest rates of errors occurring in hospital 1 that presented the best working conditions. Relevance to clinical practice. Studies such as this one have the potential to improve the quality of care.