Service Improvement Report on Intravenous Medication Errors in Paediatric and Neonatal Intensive Care Settings
Introduction
According to Elliott et al. (2020), medication errors are the most common type of error that occur in paediatric and neonatal intensive care settings. The National Health Service (NHS) estimates that medication errors are responsible for over ten thousand deaths annually and contribute to about one billion pounds in additional healthcare expenditure (Elliott et al., 2020). Due to the extensive morbidity and mortality associated with medication errors, the World Health Organisation (WHO) has allocated a global programme to aid in decreasing patient harm caused by medication errors.
One of the main aspects linked to an immense risk of medication error is intravenous medication due to the increased complexity associated with the preparation and administration of the procedure (Jones et al., 2021). It is immensely challenging to mitigate the detrimental effects of erroneous preparation because medication administered using the procedure is directly and completely absorbed and distributed into the bloodstream. Jones et al. (2021) declared intravenous medication errors to be the greatest patient safety threat in the UK. The current paper proposes a service improvement approach based on the highlighted causes of intravenous medication errors.
Background
Numerous studies have demonstrated the close association between medication errors, quality of care, and patient safety. Indeed, medication errors are detrimental to patient mortality and morbidity and often lead to delayed discharge. NHS estimates that over two hundred million medication errors occur annually, with about twenty-seven per cent leading to clinically significant harm to patients (Härkänen et al., 2019). Härkänen et al. (2019) suggested that medication errors account for at least six per cent of hospital admissions.
Intravenous (IV) medication is a common procedure in in-patient care that is commonly employed in intensive care units, emergency rooms, and wards (Kuitunen et al., 2021). As direct healthcare professionals, nurses are essential in safeguarding patient safety during IV medication processes, which are associated with inadvertent errors and recommendations violations (Kuitunen et al., 2021). Among the most commonly administered drugs using the IV route are high-risk drugs (such as opioids, insulin, and chemotherapy agents), which, at the wrong dose, could result in adverse events, including life-threatening events and fatality (Tyynismaa et al., 2017).
The intravenous medication process is intricate and involves various stages. The process involves acquiring the drug to be administered, acquiring the diluent, reconstituting the medication in the diluent, moving the drug to the patient’s location, observing for allergic reactions, examining the drug administration route, examining the dosage, examining the cannula’s patency, expelling air from the syringe, drug administration, flushing the cannula, and documentation in the prescription chart.
IV medication errors can occur at any point during the procedure. Therefore, nurses must observe the correct IV medication administration schedule and rate (Schroers et al., 2021). Panduwal and Bilaut (2020) characterised error during IV medication administration as a rate slower or faster than intended. Maintaining an accurate rate of IV medication administration is crucial to enhancing the efficacy of IV therapy and decreasing the risk of adverse effects.
A major device created with the objective of enhancing IV infusion accuracy with regard to timing, volume, and drug flow programmed by healthcare professionals is the infusion pump. They include smart pumps which have a software package with a drug library. The smart pump software can warn users if the drug parameters provided during programming deviate from recommendations, especially concerning dosage (Bacon and Hoffman, 2020). In the absence of a smart pump or infusion pump, nurses rely on counting the number of drops flowing into the drip chamber to determine the IV rate.
Numerous studies have suggested incorrect IV rate to be the most commonly occurring error, accounting for over fifty-five per cent of IV medication errors (Alghamdi et al., 2019). Although regulating the IV medication rate is an essential aspect of quality of care and patient safety, it is often overlooked. As such, the current service improvement report seeks to understand facilitating factors, IV medication error attributes, and barriers to effective interventions.
Measures
Figure 1: A fishbone analysis presentation of root cause of IV medication errors
There are various causes of IV medication errors including inadvertent mistakes. Commonly, drug preparation involves introducing a solvent into the drug vial and drawing up the dissolved drug. A major example of an error that may occur during the process is failing to detect that the drug has not completely dissolved or misreading the label (Alghamdi et al., 2019). For instance, the drawing up of an entire heparin vial by a paediatric nurse could result in an overdose. Mistakes involving drug administration or preparation often occur during rare procedures.
There are various conditions that may facilitate the occurrence of such inadvertent mistakes. According to Sutherland et al. (2019), one of the most common issues contributing to the increased risk of human error is the designing and handling of technology. Nurses may also lack knowledge of administration and preparation procedures, which are associated with handling technology. Incorrect procedures are often evident when measuring small volumes of drug solutions to administer to paediatric patients. However, fewer errors have been associated with improper handling of electronic infusion equipment.
Another common condition facilitating the manifestation of errors involves designing the technology, especially intricate drug preparation, administration, and presentation equipment (Batson et al., 2020). For instance, small labels on certain drug vials may make it challenging to identify the varying strengths of the drug, often resulting in the selection of the wrong vial. The aforementioned two conditions often result in the same type of error. Such is evident in instances involving two different drugs in identical bottles, which may create confusion. Moreover, the intricate syringe driver design, which necessitates calculating the infusion rate based on the length of the syringe, may lead to allocating an inaccurate administration rate.
According to Dirik et al. (2018), about sixteen per cent of observed IV medication errors were associated with omitted medication due to failed communication. Such was especially evident in instances where patient care involved different departments or during transfer to another department and information was not communicated. Challenges in communication between nurses and doctors may be a result of illegible handwriting on prescription notes. Some researchers have also reported communication difficulties owed to inappropriate use and examination of drug charts (Dirik et al., 2018).
Nurses have also highlighted issues associated with a heavy workload and increased distractions, which cause about fifteen per cent of reported medication errors (Kellogg et al., 2018). For instance, timely administration of IV medication and monitoring infusions may be challenging for paediatric nurses due to a heavy workload. Furthermore, patient-related issues such as an unwillingness to oblige with drug administration may make it increasingly challenging for nurses.
Besides mistakes, IV medication errors also comprise violations. Violations mainly involve bolus doses fast administration, with the bolus dose being provided in less than half the recommended period in most cases (Kuitunen et al., 2021). In most incidents involving bolus dose errors, it was of clinical significance. According to Kuitunen et al., although nurses had knowledge of the correct administration speed, they intentionally deviated from recommendations. In over sixty per cent of the reported incidents involving bolus doses, they involved administering it too fast, with nurses ‘cutting a corner’ whenever the circumstances allowed.
There are various conditions that facilitate IV medication-related violations by nurses in paediatric and neonatal intensive care settings. Wolf and Hughes (2019) suggested that nurses often do not conceive that any risk may arise from fast administration of low doses. However, given that nurses often have limited knowledge of medication, there are concerns regarding the validity of their risk assessment.
Lastly, there are some latent conditions involved in IV medication errors, including a lack of suitable design and training. According to Wolf and Hughes (2019), although nurses are taught the theoretical aspects of IV medication preparation and administration, the practical aspects are often overlooked. Nurses are often left to learn IV medication preparation and administration procedures from each other in hospitals. Moreover, the UK does not have guidelines concerning the quality and content of such training, especially regarding rare preparation procedures.
Pharmacists are also not directly involved in IV medication preparation and administration processes in paediatric and neonatal intensive care settings and have a limited understanding of the challenges nurses encounter during practice (Alghamdi et al., 2019). When teaching new nurses, senior nurses occasionally pass on bad practices, making non-adherence to guidelines acceptable practice. Such is especially evident regarding the fast administration of bolus doses, which has created a culture of unsafe IV mediation practices.
Moreover, most paediatric and neonatal intensive care settings do not have a designated area for drug preparation. IV medication preparation often takes place in the middle of a busy paediatric ward, with nurses being constantly distracted or interrupted during the procedure. Generally, the safe handling of IV medication is often not prioritised by nurses in paediatric and neonatal intensive care settings.
Design
For over two decades, medication safety has been the central focus of clinicians and academics. Such has led to increased awareness of the adverse effects of medication errors and the development of numerous interventions. Kuitunen et al. (2021) suggested that twenty-five per cent of preventable medical adverse events are linked to medication errors. Moreover, although the actual extent of the problem is unknown, there are growing concerns that an error occurs in a significant percentage of intravenous medication administrations. The COVID-19 pandemic increased the need to address patient safety issues, especially in paediatric and neonatal intensive care settings.
In 2017, WHO established the third global patient safety challenge that called for the reduction of harmful medication errors by fifty per cent over the next five years. Subsequently, NHS’s England Patient Safety Strategy encouraged hospitals to adopt electronic medication administration and prescribing systems with an aim to enhance safety and quality of care. Medication administration systems include barcode medication administration (BCMA), computerised physician order entry (CPOE), ‘smart pumps,’ and automated dispensing cabinets. Bacon and Hoffman (2020) proposed that utilising such systems along with a closed-loop medication administration process can decrease medication errors by cross-checking, prescriptions, medication, and patients through digital techniques.
In this section, the paper proposes the implementation of smart pumps by paediatric and neonatal intensive care settings to reduce IV medication errors. According to Kuitunen et al. (2022), Dose Error Reduction Systems (DERS) are central to intercepting medication errors, especially those involving an incorrect rate, pump-setting errors, and wrong dosage. A key aspect of smart pumps that promotes error prevention is providing alerts invoking the user’s reaction. Given that numerous life-threatening errors are intercepted due to the drug library’s hard limit, hospitals should consider implementing smart pump technology.
Nevertheless, Melton et al. (2019) revealed the limited effectiveness of soft limits compared to hard limits due to the increased risk of high override rates. However, reprogramming the pump after identifying a mistake or based on the alerts can intercept errors such as near-miss errors. Studies have yet to ascertain the reason clinicians override soft limit alerts, especially in the presence of low compliance rates. However, Marwitz et al. (2019) theorised the various reasons for overrides and diminished compliance, which included alert fatigue, busy environment, inappropriate alerts, inaccessible drug library, poor supervision, and absence of perceived risk.
Melton et al. (2019) emphasised the significance of flexibility during medication administration based on patient status or presenting situation, which will prevent intravenous pumps from causing delayed treatment or hindering clinical practice. It is essential for healthcare professionals to evaluate the efficacy of soft limit alerts to ascertain the effective working of smart pumps and efficiency during decision-making. Indeed, investigating the rate of infusion reprogramming following soft limit alerts may aid in preventing alert fatigue by establishing accurate soft limit parameters (Marwitz et al., 2019).
Moreover, it is recommended that the National Health Department establish a standardised drug library across varying vendors. Such would not include the utilisation of a standardised drug library across different sites but the introduction of a standardised drug library as the base drug library, allowing healthcare facilities to choose subsets that align with their area of care and hospital practice. The implementation of a drug library that complies with the standardised library would expedite efforts aimed at establishing a drug library for individual institutions. Recommendations for keeping the drug library up to date along with an evidence-based standardised drug library list would be instrumental in allowing hospitals to optimise their smart pump use.
However, there are some limitations to the use of smart pump technology despite the numerous opportunities to optimise their utilisation. A major concern regarding smart pumps is alarm fatigue, which occurs due to an overwhelming number of alerts, which can result in nurses being desensitised and may lead to delayed response or missed alarms. Moreover, due to alarm fatigue, nurses may be inclined to act inappropriately by modifying the alarm limits beyond the safe range in an effort to reduce potential alarms. They may also turn down the alert volume, making it inaudible, especially when trying to alleviate the risk of alarm fatigue or reduce stress on the patient’s family or the patient (Melton et al., 2019). Therefore, hospital administrators must assess the impact of upper soft limit values and establish appropriate values to prevent alarm fatigue due to needless alerts.
Strategy
Plan:
Forming a multi-disciplinary steering committee
The first step when implementing a smart pump system is the preparation phase during which the hospital administration creates a multi-disciplinary steering committee. According to Howlett et al. (2022), the successful implementation of a smart pump system relies on perceiving the endeavour as an institutional undertaking rather than a departmental responsibility. The process should include staff from different departments, including nurses, biometric engineers, IT system experts, pharmacists, and doctors. As such, the implementation of a smart infusion pump is considered a formal process that requires the contribution of different stakeholders. Moreover, it should be considered a patient safety initiative rather than a pump replacement initiative.
Dosing Units and Drug Concentration Standardisation
Moreover, smart IV infusion systems require the utilisation of drug libraries and the installation of wireless servers. As such, during the implementation of a smart pump system, a comprehensive readiness evaluation is necessary. Hospitals are required to standardise the dosing units and drug concentrations to guarantee synchronicity of information in the smart pump libraries and doctor orders. Standardisation is also crucial to Dose Error Reduction System (DERS) compliance. Therefore, standardisation of dossing units and drug concentrations is an indispensable prerequisite to the implementation of smart pumps.
Do:
Develop Library
As aforementioned, in order for smart pumps to be completely integrated, hospitals are required to create, modify, and maintain drug libraries for varying clinical care operations to establish library subsets for given patient groups.
Key Systems Integration
According to Joseph et al. (2020), for hospitals to derive benefits from the implementation of smart pump systems, they have to be extensively integrated with other systems. Due to the absence of a systemic approach for dealing with medication safety concerns, fragmented solutions are often observed in hospitals, which may result in unintended challenges. After hospitals have prioritised wireless network-based information download and upload and have also fulfilled the aforementioned standardisation requirement, an adaptable approach can be employed in the implementation of smart pumps while completing efforts to fully integrate the system. Frisch (2019) also recommended the creation of a long-term plan that prioritises the integration of associated information technology systems and the utilisation of radio frequency identification (RFID) tags among patients and for medication identification.
Addressing Issues that may Arise due to the Cultural Shift and Process Modification
As with implementing changes in any organisation, the implementation of a smart pump system is expected to disrupt organisational culture and alter existing processes, which if not properly addressed may impact the quality of care. Therefore, before implementing smart pumps, hospitals should identify and prepare for changes in the processes and culture. The most commonly affected groups by the shift to smart infusion systems are nurses and pharmacists. For instance, the implementation of smart infusion systems may necessitate the creation of a standard concentration platform, which may lead to changing the responsibility of mixing drugs from nurses to pharmacists. Moreover, the programming of traditional pumps and smart pumps significantly differs, which may present some challenges.
Installing the Wireless Infrastructure
In order to fully realise the benefits of smart pump technology and maintain frequent drug library updates, a wireless network environment that is ready for smart pump installation is crucial. However, some institutions have failed to install wireless connectivity before implementing smart pumps, which has led institutions to reap the full benefits of the smart pump system. Such is especially true regarding the benefits associated with rapid drug library updates and evaluating compliance with drug templates based on data downloaded using wireless networks.
Study:
Evaluation and Acquisition of the Smart Pump System
There are different varieties of smart pumps and their software that exist in the market and are provided by different suppliers. When examining products available in the market for suitability in a particular institution, the steering committee must consider all aspects of the smart infusion systems as opposed to a narrow focus on individual pumps. Among the aspects that should be considered are the continuous quality improvement software and the drug library software.
Act:
Training and Policy Development
Furthermore, institutions must establish a training programme based on changes to existing processes and staff technical skills necessary to fully implement the smart pump system.
DERS Compliance
One of the main aspects institutions have to deal with following the installation of the smart pump system is evaluating Dose Error Reduction System compliance. User entry into the DERS is essential to the optimisation of smart pump technology. Institutions may not realise any safety benefits and may experience a negative return on investment if they programme in the generic mode.
Monitoring
Constant maintenance of the entire system and compliance should be evaluated, with barriers to successful adoption being identified and eliminated.
Conclusion
In conclusion, the above service improvement paper reveals intravenous medication errors are the most prevalent and detrimental errors in paediatric and neonatal intensive care settings. It examines the aspects and conditions facilitating the manifestation of medication errors. Lastly, it proposes smart infusion systems as the ideal intervention and provides an implementation strategy.
Reference List
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