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Majority of IV Medication Errors Linked to Clinical Practice, Not Technology


Mistakes that occur during the administration of intravenous (IV) medications have long been one of the most common types of errors in hospitals, and for years many experts have believed that advances in technology—such as the use of so-called smart pumps—were the key to solving that problem. However, a new study suggests that eliminating administration errors is far more complex: Sound clinical practices and an adherence to those practices are crucial, as well as achieving true interoperability.

A new multihospital study published online in BMJ Quality & Safety calculated that more than half of infusions of IV medications contained errors—most of which had a low risk of patient harm—and the majority of these errors  were due to deviations in hospital policy.

Based on comparisons with previous studies, the researchers noted that medication-related errors were much lower, providing evidence that the implementation of smart pump technology has, in fact, improved infusion safety. However, the authors concluded that there was still “room for improvement” and that the next steps should focus on reviewing existing practices and policies pertaining to medication administration and achieving smart pump interoperability.

Smart pumps were developed to help reduce adverse drug events and medication administration errors through built-in safety features such as drug libraries and dose error reduction systems. According to a national survey conducted by the American Society of Health-System Pharmacists in 2012, 77 percent of hospitals in the United States use smart pump technology.

To provide insight into the type and frequency of errors that occur after hospitals have implemented smart pump technology, David Bates, MD, senior vice president and chief innovation officer at Brigham and Women’s Hospital in Boston, and a multidisciplinary team of researchers assessed 1,164 medication administrations conducted at 10 hospitals of varying sizes. All of these hospitals utilized smart pumps for infusions, although the pumps came from a variety of vendors.

During the study, 60 percent of infusions contained one or more errors. Violations of IV labeling and tubing change policies, which vary between hospitals, accounted for approximately 65 percent of the observed mistakes.

“Since these errors are not directly related to the use of smart pumps, these finding suggest that smart pump technology alone cannot fully prevent errors associated with intravenous infusions,” the researchers concluded. They went on to say that by characterizing these types of errors, they had identified opportunities to “streamline the intravenous medication administration process to avoid unintended consequences.”

Of the handful of potentially serious errors noted by the researchers, infusing medications at the wrong rate was observed most frequently, followed by administering unauthorized medications and omitting medications. Overall, just five of these errors were considered to possibly be able to cause temporary harm.

According to the researchers, none of the potentially harmful medication errors could have been prevented using current smart pump technology in the absence of interoperability. However, most of these mistakes could be prevented if “closed-loop interoperability between the smart pump and EHR was implemented,” the authors wrote.

In a closed-looped system, smart pumps can be automatically programed with a medication order using the patient’s EHR. Then the nurse must verify the information on the smart pump and accept the data—drug name, infusion rate, volume, and concentration—before the infusion can begin.

This study was funded by the AAMI Foundation from a grant provided by BD, formerly CareFusion, and is the result of a three-year collaboration. Bates presented the preliminary results of this research at last year’s kickoff meeting for the National Coalition for Infusion Therapy Safety.

“This research illustrates that while we have come a long way since our initial conversations about infusion safety at the 2010 AAMI/FDA Infusion Device Summit, there is still more work to do,” says Marilyn Neder Flack, senior vice president of patient safety initiatives at AAMI and executive director of the AAMI Foundation. “Researchers such as Dr. Bates are providing the clinical data that members of the AAMI Foundation’s National Coalition for Infusion Therapy Safety need to find evidence-based solutions.”

Source: AAMI

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