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AJN, American Journal of Nursing:
State of the Science on Safe Medication Administration

Toward Safer IV Medication Administration: The narrow safety margins of many IV medications make this route particularly dangerous.

Nicholas, Patrice K. DNSc, MPH, RN, APRN, BC; Agius, Christine R. MSN, RNC, APRN, BC

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Patrice K. Nicholas is professor and chairperson of Advanced Practice at MGH Institute of Health Professions, and nurse administrator at Brigham and Women’s Hospital in Boston, where Christine R. Agius is a staff nurse. Contact author: Christine R. Agius, cagius@partners.org.

Intravenous medication administration and infusion technology have changed dramatically over the past three decades. The confluence of newly developed technologies, including automated dispensing cabinets (ADCs), computerized provider order entry (CPOE), and bar-code systems such as the electronic medication administration and recording (EMAR) systems, as well as computerized infusion devices, presents the potential for IV medication administration to be safer and more efficient.

Of the seven goals identified in the 2004 National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), five relate to IV medication administration. 1 The first goal, improving the accuracy of patient identification, calls for the use of at least two identifiers when medications or blood products are administered. The second is improving the effectiveness of communication among caregivers, which can be achieved, in part, by standardizing abbreviations, acronyms, and symbols pertaining to medication. The third is improving safety when “high-alert” medications are used, many of which are administered intravenously. The others are improving the safety of infusion pumps and the effectiveness of clinical alarm systems––infusion pump alarms are included within the latter goal.

Preventing medication errors is not a new concern, but recent advances in technology offer possibilities for improving medication administration and maximizing patient safety. 2 This article focuses on medical errors and adverse drug events (ADEs) attributable to IV medication administration, outlining the causes of IV medication administration errors, describing technology innovations, reviewing nurses’ roles in the future, and hypothesizing implications in nursing practice.

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THE SCOPE OF THE PROBLEM

The 2000 Institute of Medicine (IOM) report entitled To Err Is Human: Building A Safer Health System indicates that 44,000 to 98,000 Americans die each year because of medical errors, 3 and that one of every 854 deaths among inpatients is the result of a medication error. Furthermore, an estimated 6.5 ADEs occur per 100 admissions, 28% of them preventable, 3 medication prescription error being the most common cause. 4, 5

In the past, practitioners have focused on medication errors and adverse drug events in general, not on errors associated with IV medication administration specifically, but now attention is being concentrated more on the importance of accuracy in the latter, partly because so many medications are now delivered by that route, often with infusion devices. In addition, IV administration often involves injecting fast-acting, powerful substances directly into the patient’s bloodstream, 6 and nothing can be done to stop medication from entering the circulation. 7

In a study published in 2003, medication errors were reported in 49% of all IV medication administrations, 8 most of them occurring with IV push medications, and most of those the result of nurses administering bolus doses faster than was recommended. 8 The use of infusion devices accounts for as many as 35% of all medication errors resulting in significant harm to patients. 9

Often, inpatients receive numerous IV medications concurrently, increasing the possibility of error. Multidepartmental work settings, limited use of technology, and human factors may contribute to IV medication administration errors. Cullen and colleagues found that the rate of preventable or potential ADEs associated with the use of oral and IV medications was twice as high in ICUs as it was on other units. 10 However, when adjustments were made for the number of drugs ordered, there was no significant difference, and the authors suggest that the quantity of drugs used rather than an overworked staff functioning under stress in an environment with many distractions is a major cause of ADE. In a series of editorials, Davis suggests that human factors (working shifts longer than 12 hours, for example), a lack of knowledge, and the failure of safety mechanisms are sources of medication error. 11–13

Often, critically ill patients receive potent “high-alert” IV medications considered to have narrow safety margins (including potassium chloride, dobutamine [Dobutrex], and diltiazem [Cardizem and others]) and that must therefore be carefully increased by the nurse. Errors associated with administering high-alert medications pose even greater risks.

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THE USE OF TECHNOLOGY TO REDUCE THE INCIDENCE OF IV MEDICATION ERROR

Technology can help make IV medication administration safer by providing detailed information on IV medication administration practices at the point of care, when nurses need it, and by minimizing errors attributable using the wrong drug, the wrong dosage, or the wrong rate of administration. New and emerging technologies that may facilitate safer IV medication administration include ADCs, bar coding, more advanced infusion devices, computerized ways of signing out medications, hand-held personal digital assistants (PDAs), and wireless access to electronic medical records. Better programmable IV infusion pumps may improve the safety of medication administration, especially when infusion protocols are embedded into the pump software. 14, 15 Table 1, page 27, summarizes the strengths and weaknesses of three types of technologic devices used in administering IV medications.

Table 1
Table 1
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ADCs provide an efficient way of monitoring medication administration and preventing IV medication errors. At Brigham and Women’s Hospital in Boston, ADCs are used on all inpatient units and in most outpatient clinics, and every RN who administers medication is given a user name and password to gain access. After the physician orders medications, the pharmacist reviews each one and logs it into the ADC under the patient’s name and medical record number. When it comes time to administer medication, the nurse clicks on each drug onscreen, revealing the dosage and quantity specified, and the ADC opens the drawer electronically so that the nurse can remove it. Medications that might be needed in emergencies also are stored in the ADCs and are accessible at all times. On cardiology units, for example, nitroglycerin (Nitro-Bid IV, Tridil), atropine (Sal-Tropine), and morphine sulfate are readily available. At some institutions a fingerprint is used to gain access to the ADC to minimize the possibility of information being used by unauthorized personnel.

Electronic charting represents a new strategy for reducing the incidence of medication errors in the inpatient setting. In such a system, all medications have a bar code on each dose package, which the nurse scans prior to administration. The patient’s identification band and the nurse’s badge also are scanned. The Veterans Administration was one of the first health care organizations to adopt that method of medication administration, 16 and Brigham and Women’s Hospital is testing an EMAR system using bar code technology that eventually will be implemented throughout the hospital.

An EMAR system combining drug utilization reviews (DURs) and electronic medication records links vital information to limit the number of human errors made in medication administration. ADEs can be prevented when nurses conduct efficient drug searches using DURs, but searches that result in many choices or that make a drug hard to find may increase “free-text” ordering (rather than ordering by code), in which the drug selection data base is bypassed, increasing the likelihood of system error. 17

Hospitals are implementing risk-reduction strategies that involve the conjoined use of CPOE systems, bar-code point-of-care systems, and programmable IV pumps that accommodate both technologies. The pumps issue alarms that warn nurses of a breach of any of the five “rights” of medication administration: the right patient receiving the right amount of the right drug at the right time via the right route of administration. Such infusion pumps can be designed with an electronic library of IV drugs and infusion protocols in pump software that is specific to the facility and compares the medication dose or rate of infusion with the limits that have been set at the hospital in which they are used, thereby preventing error. If the nurse attempts to administer a drug dose that is outside those limits, the infusion pump either stops or sounds an alarm. Some programmable pumps integrate within their operations patient monitoring and other parameters, such as patient age or clinical condition, drug compatibility information, and infusion directions.

Tools such as CPOE and PDAs can help to reduce the incidence of medication error at the first step––the ordering or prescribing of the drug. These tools and wireless access have the capability of minimizing IV medication error by allowing health care providers quick access to updated information. Such technology can help with the prescribing of IV medications, such as those with doses based on weight or doses that must be adjusted for a patient with renal failure, by providing the prescriber with information on dosing and drug interactions.

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ADDRESSING THE PROBLEM OF MEDICATION ERROR

With all of the advances in technology, why do medication errors continue to occur? Some result from system failures, whereas others are attributable to human error. 15 Understanding the complex factors operating in IV medication administration (technologic, human, and system-related) is necessary to prevent medication errors.

For example, errors occurring as drugs are restocked, storing drugs that look alike (or the names of which sound alike) in the same drawer, and distributing medication without the pharmacist’s review can create unsafe circumstances that can precipitate the commission of error, as well as incorrect inputting of data. 15 A missing decimal point or an additional zero could result in a lethal overdose. In clinical practice settings, pressing one wrong key can result in a serious medication error.

An interdisciplinary approach to medication administration, with an emphasis on the IV route, is essential to patient safety. Nurses and pharmacists do not always agree on which drugs should be considered “high-alert” ones that pose a heightened risk of significant harm when used improperly. In one survey, nurses identified IV adrenergic antagonists and agonists, narcotic analgesics, and liposomal forms of drugs as high-alert medications, whereas pharmacists thought that hypertonic sodium chloride, warfarin, and insulin were more deserving of that designation. 15 Pharmacists, nurses, physicians, and other practitioners must work together to develop, institute, and evaluate IV medication administration systems and improve communication among them to achieve that goal.

Herout and Erstad studied the error rate associated with continuously infused medications and evaluated patients’ heights and weights (actual, ideal, and “dry”) used to calculate doses. 18 During the one-month period of data collection, the error rate was 105.9 per 1,000 “patient days,” much higher than Leape and colleagues’ finding 35 errors per 1,000 patient days over a six-month period. 19 Medications delivered by continuous infusion, particularly ones that are based on patients’ weights, can contribute to higher rates of medication error. 18 Strategies that can be employed to prevent such errors include standardizing drip concentrations and infusion units (using mcg/kg/min or mcg/min, [but not both], for example), consistently monitoring infusion pump rates, and continuing education and in-service education of all health care professionals.

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CONTINUOUS PROFESSIONAL EDUCATION

Medication education should be ongoing among all nurses. Information on new medications is rapidly changing, and all health care practitioners must keep current in the most recent knowledge regarding the prescribing, dispensing, and administration of them. Clinicians’ education should focus on three concerns––medication administration technology (for example, ADCs, PDAs, EMAR, and bar coding), high-alert medications, and strategies––to reduce risk and provide patient education in medication practices throughout the health care continuum, from the technology used in the hospital to home care.

Education should be also directed toward new nurses and physicians who may be unfamiliar with medication ordering, doses, and boluses. Newly licensed professionals (both nurses and physicians) should have both a mentor and access to support systems, including technologic support. There often is a body of knowledge and a pharmacopeia unique to a medical specialty, and even experienced RNs benefit from having a mentor when they move from a familiar clinical practice setting to a new one.

Older nurses may adapt less readily than younger ones do to information technology and computer applications in medication administration, and it is even more important that continuing education be provided to them. The nurse educator must be accessible to all nurses in order to respond to issues in IV medication administration and technology as they arise.

Little or no written drug information and medication safety education materials are available to nurses for patient education.

Education can be sought from outside the facility as well. A useful resource is the Institute for Safe Medication Practices (ISMP), a nonprofit organization that educates the health care community in medication safety. A recent edition of its Medication Safety Alert! suggests the use of “tall man lettering” as a way to help prevent errors involving medications with names that look alike––labels reading vinBLAStine and vinCRIStine clearly differentiate the medications, for example. Grasha and colleagues found that such lettering reduced drug selection errors by 35% in a pharmacy-dispensing environment that they simulated. 20

Staff competencies in IV medication administration should be reviewed annually, along with cardiopulmonary resuscitation, defibrillation certification, and competencies pertaining to fire and safety. Often, there are particular competency schedules for nurses working on specialty units. In cardiology nursing practice, for example, competencies reviewed include defibrillation, temporary pacing, and identifying arrhythmias. Competencies in IV technology administration should be added to that list.

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EDUCATING PATIENTS AND FAMILIES

The education of the patient and family is an important responsibility of the nurse in any practice setting. Educating them in IV medications is more complex than educating them in oral ones, especially when programmable pumps and other devices are involved. Web-based teaching can facilitate patient and family education and improve their problem-solving techniques. It is especially important that patients and families in home care settings, who may be independently responsible for managing IV medications, are educated in those medications and in the use of infusion pumps, and advised of the need to be greatly vigilant in the prevention of errors of administration.

According to a recent ISMP report, nurses find that little or no written drug information and medication safety education materials are available for patient education, 21 and that the materials that do exist lack clarity or are incompatible with the patients’ reading level and knowledge of health issues, or are not in patients’ native languages. To address the latter problems, patients and families should be included in the development of medication safety education materials.

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THE FUTURE HOSPITAL WORK ENVIRONMENT

Technologic innovations may decrease the likelihood of medication errors occurring in the hospital, but they also increase the level of monitoring required for each patient, even if the incidence of IV medication errors decreases.

The clinical data that patient care assistants collect (including electrocardiographic data, blood pressure readings, patient weights, and blood glucose measurements) determine clinical decisions and IV medication administration. Eventually, all those data may be linked to clinical decision-making tools that are integrated with IV medication administration. In “paperless” health care systems in which all clinical data are obtained electronically and entered into a computerized medical record, clinical decisions would be based solely on that information.

Another means of reducing errors associated with IV medications and infusion technology is one based on the failure mode and effects analysis process recommended by JCAHO, which itself is based on the assumption that errors will occur and that health care providers should prevent them. Employing that process, an interdisciplinary team of nurses, physicians, pharmacists, product engineers, risk managers, and quality assurance staff could identify the types of errors and failures that could occur with infusion pump use. Apkon and colleagues used it to design a safer approach to IV drug infusion and found that standardizing infusion delivery reduced the frequency of IV medication and infusion errors, leading toward a safer delivery system. 22

In the near future, innovations in health care technology may include robotic devices that promote the safety of IV medication administration and pump technology. Such technology may shorten work hours, diminish fatigue, improve the interaction among physicians, nurses, pharmacists, and patients, and minimize ADEs. Robotic technology may provide a critical link in gathering clinical information and improving communication throughout health care disciplines. 23

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RESEARCH PRIORITIES

Research into reducing medication errors effected by infusion technology will support the development and implementation of other technologies that could be used in administering IV medication more safely. Another priority is educating nurses on the job, and patients and their families at home, in infusion technology and the prevention of medication errors. In addition, research is needed in technologic advances and how nurses and other health care providers can benefit.

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SUMMARY

The research and practice literature suggests that the reduction of medication error rates and IV medication errors is a complex problem. 24–26 Errors in IV medication administration can be reduced with the use of infusion technology and risk-reduction strategies that incorporate CPOE and bar-code point-of-care systems as well as readily available drug library information at the point of care. Educating patients and their families and the continuing education of nurses in IV medications and infusion technology are essential. Technology and education present great potential in the prevention of serious errors in IV medication administration, making that aspect of patient care safer.

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The Nurse’s View: When a Patient Dies from a Medication Error

By Zane Robinson Wolf PhD, RN

Zane Robinson Wolf is dean of the La Salle University School of Nursing in Philadelphia, where she is also a professor. Contact author: wolf@lasalle.edu.

Medication errors are seldom fatal. But if a patient dies after a medication error, even if the error itself is not the primary cause of death, the effect on a nurse involved in the error is enormous.

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Here is an account of one nurse’s experience after a medication error that preceded the death of her patient.

My patient was having premature ventricular contractions. I took the lidocaine drip off his pump and gave him a bolus of the drip. That was common practice at the time, although now drips stay on pumps. My patient then had a seizure, and I was afraid for him. When he went into cardiac arrest, we attempted to resuscitate him, but he died.

I felt very guilty, worried, humiliated, embarrassed, and defensive. I felt frustrated, and I wanted to make amends. I was concerned about my reputation and feared that my coworkers would not respect me; however, my fellow nurses and nurse manager were supportive. Since the error, I have a heightened sense of responsibility.

This response is typical of health care professionals who have made serious medication errors. They feel guilty, worried, and embarrassed. They wish to make amends. They worry about the effects of the mistake on the patient and on their own careers and fear disciplinary action or being viewed as incompetent. Such health care professionals subsequently become hypervigilant to avoid additional errors. Although they want the support of their colleagues, their friends and family tend to be more supportive.

In 1999 I surveyed health care professionals anonymously about serious medication errors they had made in their careers. 1 Although the survey was sent to 3,000 nurses, 3,000 physicians, and 3,000 pharmacists, the response rate was low; only 402 completed surveys were returned. Of those, 208 were from nurses. I found that 11 patients of those who responded had died as a result of reported medication errors.

Given the low response rate and the low number of fatal errors reported, I am currently undertaking another study. I am interviewing health care professionals identified by the media and reported to the Institute for Safe Medication Practices as being involved in a medication error involving a patient who died. At present, I have had more success contacting nurses than physicians.

The death of a patient resulting from a medication error is a mark that nurses carry to their grave.

1. Wolf ZR, et al. Responses and concerns of healthcare providers to medication errors. Clin Nurse Spec 2000;14(6):278–87; quiz 288–90. Cited Here...

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REFERENCES

1. Joint Commission on Accreditation of Healthcare Organizations. National patient safety goals for 2005 and 2004. 2004. http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm.

2. Roark DC. Bar codes and drug administration. Am J Nurs 2004;104(1):63–6.

3. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academies Press; 2000.

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20. Grasha A, et al. Executive summary. In:Cognitive systems perspective on human performance in the pharmacy: implications for accuracy, effectiveness and job satisfaction. Executive Summary Report. Alexandria, VA: National Association of Chain Drug Stores; 2000.

21. Institute for Safe Medication Practices. Medication Safety Alert! 2004;9(2).

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23. Institute for Safe Medication Practices. Medication Safety Alert! 2004;2(2).

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26. Grissinger M, Globus NJ. How technology affects your risk of medication errors. Nursing 2004;34(1):36–41; quiz 41–42.

© 2005 Lippincott Williams & Wilkins, Inc.

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