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Two-Person Checking Strategy Can Cut IV Infusion Errors

November 11, 2016

By Joan Stephenson

NEW YORK (Reuters Health) - Using a two-person verification process to determine whether a medication infusion pump has been correctly programmed with the patient's weight and the appropriate drug dosage can help reduce potentially disastrous errors, new research shows.

"This will promote a safe health care culture and can potentially reduce catastrophic harm," first author Dr. Rajeev Subramanyam, of Cincinnati Children's Hospital Medical Center in Ohio, told Reuters Health by email.

More than 56,000 adverse events and 710 deaths tied to the use of infusion devices were reported to the Food and Drug Administration over a five-year span from 2005 to 2009. Children are at particular risk for medication errors because of the need for precise weight-based dosing, the authors noted.

Although the use of "smart" pumps has substantially improved patient safety, errors related to programming the devices still occur.

"We had two infusion pump programming errors in our practice related to incorrect patient weight/drug dose programming," explained Dr. Subramanyam. Although these errors were noted immediately and did not result in patient harm, "we found it imperative to find ways to improve the safety of infusion medication administration," he said.

Dr. Subramanyam and colleagues conducted a quality improvement initiative between 2014 and 2015, to implement and test a two-person verification system when using an infusion pump to provide anesthesia or sedation for children undergoing radiologic imaging at Cincinnati Children's Hospital Medical Center.

In the verification process, after the first person programs the infusion pump, the second person walks through each step, paying particular attention to the programming for the patient's weight and drug dosage.

After identifying key "drivers" - types of changes or processes that might help reduce infusion medication errors - the researchers conducted a series of tests ("plan-do-study-act" cycles) of various interventions to see if they improved compliance with the double-checking verification process.

Interventions included educating clinicians about the verification process and checking compliance; use of visual aids, such as written reminders in front of computers in MRI scanner areas; fostering "stakeholder buy-in" through such measures as displaying weekly updated run charts indicating compliance; and documentation of the verification process in electronic medical records.

The rate of two-person verification (that an infusion pump was correctly programmed) increased from 0% to 90%, the researchers report in Pediatrics, online November 9.

Four programming errors were detected during the project and were corrected before they could affect the patient.

"These instances of error rectification were a major impetus for stakeholder buy-in," the authors noted.

The initiative reduced infusion pump medication errors over the course of two years from four errors per month to 1 error per month.

"The culture of change has been sustained to date by incorporating the process into the procedural timeout," a routine checklist that is addressed before giving anesthesia or sedation, the researchers said.

The process also did not delay case start, the time at which the anesthetic or sedative medication began.

"With the use of a quality improvement approach using a plan-do-study-act cycle strategy, a safe culture of intravenous infusion medication use was established," said Dr. Subramanyam. "The process was made sustainable by making modifications in our practice."

The findings are generalizable to any care setting where infusion of medications occurs, Dr. Subramanyam said.

"Some factors that are key to success include education about the improvement project, constant communication with all the care providers, the demonstration of the impact of the project early and frequently, and ensuring sustainability by making adjustments to the practice," he said.

The quality-improvement effort, which targeted relatively infrequent but high-risk errors, was on top of other safety systems already in place, including electronic health records and smart intravenous pumps that check for medication dosages that are outside certain bounds, noted Dr. David W. Bates, of Brigham and Women's Hospital, who was not involved in the research.

"Limitations of the approach are that it was implemented in only one small area and would be hard and labor-intensive to generalize it more broadly," Dr. Bates told Reuters Health by email.

"In general, though, the quality-improvement approaches described in the study can be used to tackle many problems," he added.

The study had no external funding and the authors reported no disclosures.


Pediatrics 2016.

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