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Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Reducing IV Errors in the Critical Care SettingKathryn Jenkins, John Fanikos, MBA, RPhMarch 2012 : IV Safety - Vol. Medication errors represent a clear and significant danger in the health care setting, especially for those patients that are critically ill and hospitalized in an intensive care unit (ICU), where the probability of a damaging adverse drug event (ADE) due to error is more pronounced. From a more concrete standpoint, the implementation of IV medication safety technology requires in-depth supplier and product assessment. ConclusionAdopting a wide range of safety initiatives in the critical care setting can significantly reduce the volume and severity of IV medication errors and any resulting ADEs. Kathryn Jenkins is a student at the University of Delaware studying biology and psychology. John Fanikos, MBA, RPh, the director of pharmacy business and financial services at BWH, is also assistant professor of clinical pharmacy practice at Northeastern University and at the Massachusetts College of Pharmacy (MCP). An acute prescription is one which has (usually) been given as a one-off and is not intended to be given again and again. Repeat prescriptions – as detailed in the practice leaflet, all prescription requests will be ready within 48 hours (2 working days).
Medication Request –  the patient later requests the repeat medication either via the repeat script (preferred), electronically or via telephone.
Prescription storage – admin staff place the prescription in a secure holding area until patient arrives to pick it up. When prescribing a new repeat, try and syncronise – match up all repeat medications in terms of quantities (that it runs out when other medication runs out) and review dates. Staff need to be very careful with requests for repeat medication via e-mail or the internet. Remember that telephone requests for medication can  (i) block more urgent calls, (ii) block patients trying to make appointments, (iii) distract receptionists whilst processing requests, and  (iv) lead to one request not being processed before the next telephone call is answered.
The Practice Manager will check that the computer is set so that compliance issues are flagged and a message over ridden before the receptionist can continue. Medicines which can be taken on a ‘when required’ basis may be flagged by the computer as being underused e.g. If the review date is approaching, the item can be issued and the patient informed that a review appointment is due e.g.
Repeat prescriptions need to be prepared with accuracy by a receptionist who is trained up in the role of repeat prescribing. In order to reduce the risk of mistakes, the receptionist who has the task of processing the repeat prescriptions should do so in a quiet area where they can concentrate and not be distracted.
Prescriptions need to be printed and processed within 48 hours of recieving the request from the patient.  When accepting a request from a patient for a repeat prescription, please tell them that the turnaround time for a prescription will be 2 days and that they should not come to collect it before then. Provide a record of the issue in the patients notes – so that others can see what has been given. Provide the patient with a copy of the items that have been authorised as a repeat prescription, which can be used to request a repeat. Can be used as a source of data and audit to improve prescribing quality and maximise cost effectiveness. Does the drug continue to be effective – is it having the desired effect, are they on the right dose?  Is there a better and more suitable alternative? Determining which medicines are being taken and deleting any medicines which are not being ordered and duplicate medicines.  It is good practice to periodically run searches to determine which medications are not being ordered. All repeat medications must be commenced on the computerised patient repeats prescription list by a GP and authorised for a set number of issues. Normally the review date for stable medicines is set at 12 months but it should be set earlier for patients who should be seen more often (e.g. The review date acts as a safety mechanism to ensure that medicines are flagged back to the prescriber for review. The review date should be the same for all the medicines (except those where a particular medicine may need an earlier review). An entry needs to be made in the medical records at the time of medication review to indicate that it has occurred, noting any changes. Once prescriptions are signed, they should be stored in a secure area away from public access.  In Ashcroft Surgery, there is a prescription filing cabinet in the receptionists area (which is partitioned off from the patient waiting area). Queries about a medication (for example, if the patient asks about side effects or interactions with other drugs or asking for a medication to come off their repeat list). Our Practice Manager will ensure that staff will only have functions on their smart cards which are appropriate to their specific role.
All scripts requiring a doctor’s agreement and signing will be placed in the ‘prescription’ tray in the reception room. From 0830, any new prescription requests from 0830 until 2pm should be put into the emptied prescription tray.
At 2pm empty this tray and distribute the prescriptions across all the GPs doing surgeries – put them in their individual prescription trays and place them by their keyboards. After 2pm– Those those that have been collected should be put in the emptied prescription tray, ready to dish out to the working GPs the next following morning.  Remember, only to distribute to GPs doing surgeries, not GPs who are working but doing something else like medical student or gp-trainee tutorials. The Doctors must deal with all scripts during or at the end of their clinical session and return them to the admin ‘signed scripts’ tray. If the prescription is not needed urgently, ask them to present their completed request form.
Do issue this time, but explain that this is a one-off favour to them and update the screen message (i.e. Returned request forms should be given to the Practice Manager who will confirm the authorisation in writing to the patient. Patients should only be ringing for repeat prescriptions during 2-4pm on Tuesdays, Wednesdays and Fridays.  If they ring outside these periods, deal with their query as a one-off and advise them of the correct times.


Confirm that the patient is authorised by looking for code & description in Active Problems list. Confirm to which chemist – if they want to collect it or get it collected by a friend or relative, then politely ask them why this not done to deliver the repeat slip. Telephone Number (on which to be contacted should the prescriber refuse to issue the request).
And finally, remember that some of these patients might benefit from email us their required repeats rather than telling us over the phone – so advise them as appropriate to their abilities and resources.
Try to ensure any prescriptions you have promised to provide are signed before you complete your shift or passed onto another member of staff for their overview. Tell the patient that you cannot see it on their usual set of repeat medicines and ask them politely why they are making the request.
Advise them that you can see it on their acute list but ask them whether they know if the doctor planned to give it as a one-off or as something to be taken regularly. If the patient says it was meant to be a repeat, pass onto the doctor with a note asking if it should be on a repeat.
Tell them that drugs not given by the doctor cannot be given without the doctor assessing them first. Patient should see or talk with a GP for a decision on whether to give the medication or not. And that urgent requests like these result in interrupting the doctors who are already busy seeing ill patients. And that urgent requests like these create unnecessary chaos for the practice who already have much to do. Try to ensure that any prescription you have ‘promised’ is signed & available for collection before the end of your shift or agree with another member of staff for them to oversee it. Doctor to check review date is accurate – for example, has a review been done but date not reset? Try to find out why the patient is asking for more medication before the expected time  – ask the patient.
If ordering very early (and no explanation is available) do not issue but put clear message on screen.  Again, contact the patients as to why they are asking for it so early.
Then issue the prescription but bring it to the attention of the GP with a note on the prescription saying ‘Under-using’  and give the reason for the underusage if you have managed to determine it through talking with the patient. If it is a replacement request, the patient needs to contact the Air Products oxygen cylinder provider direct with whom that should have been authorised with via the HOOF process.
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Nurses were accused of making mistakes like crushing or allowing patients to chew pills which should be taken whole and mixing medicines together to make them easier to swallow. In 817 cases an error was made, the study said, with patients who have difficulty swallowing three times more at risk than the average patient.
Omnicell® G4 Unity automated dispensing cabinets (ADCs) create better workflow to improve how medications are managed. Omnicell ADCs are linked via a shared database with our Controlled Substance Manager and other solutions on the Unity platform.
Omnicell is the only company to offer a Medication Label Printer integrated within the ADC. OmniDispenser™ dispenses each dose individually, virtually eliminating the need for countbacks. High capacity storage accommodates oral solids, ampules, vials, oral liquids, IVs, bulk stock, etc. Wide array of drawer styles meets needs of each patient care area as well as long-term care sites. Medications and supplies can be combined in a single cabinet, adding convenience and saving space. Universal eBox (electronics) used across the Omnicell product line ensures quick and efficient service. Enables users to access the cabinet via fingerprint scan only, which helps prevent unauthorized users from gaining access. Stores medications in a separate, secured location in the cabinet and dispenses each dose individually.
Virtually eliminates time-consuming countbacks and discrepancies related to controlled substances. Enables you to store, manage and track up to 100% of medications needed for every patient within the automated dispensing cabinet. Allows nurses to print patient-specific labels during medication issue for medications that won't be administered immediately. Gives nurses the freedom to remotely interact with the Omnicell cabinet from anywhere in the patient care area. Enables 2D bar code scanning to confirm the identity of a medication or supply at all points of access: restock, selected issues, and returns. Interfaces with hospital pharmacy information system to access patient-specific orders, administration schedules, and allergy information. Provides a filtered list of "due" medication orders to the nurse for greater dispensing efficiency and enhanced patient safety. Omnicell automated dispensing cabinets come in a wide range of formats and can be configured with a variety of drawer types. Furthermore, intravenous (IV) medication errors present a distinct risk to patients, as approximately two out of three patients in the ICU are administered multiple IV drugs, which only increases the odds that an error will lead to an ADE.
Successful integration of these elements requires open communication, collaboration, and dedication toward a mutual goal. Depending on each facility’s current level of technology adoption, the driving forces for selection should include estimates of the speed with which the adoption will impact the initial cost and ROI, the staff resources and time required for implementation, and the potential to reduce patient harm due to medication errors.


Implementing IV medication safety systems, standardizing drug names, standardizing concentrations, and purchasing ready-to-use medications are just a few solutions to drastically improve patient safety and contribute to operating efficiencies.
A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Second consensus development conference on the safety of intravenous drug delivery systems-2008.
Her research interests include diagnostics and infectious disease and she intends to pursue a career in medicine. Patients should be advised at the time of request that the doctor may wish to see them before the item is issued. This does not mean that patients telephoning outside these hours should be refused medication, instead the request should be accepted and the patient reminded of the designated times when requests should be made. There is evidence to suggest that on screen reminders are more effective than feedback in modifying behaviour related to medicines management. If the prescription states ‘when required’ then a maximum dose needs to be stated.   MDU or ‘as directed’ are not acceptable. Explain to them that their immediate request puts unnecessary pressure on the practice because it interrupts GPs who are busy attending to patients. With these factors being tied to reimbursement, it’s more important than ever to improve nursing workflow across the healthcare enterprise, including long-term care settings. This integrated platform allows a more automated chain of custody that provides greater visibility and helps reduce time spent resolving discrepancies. Because IV medications are far more likely to cause harm or death compared to other types of medication errors, this clearly magnifies the importance of having comprehensive and effective IV safety measures in place.
Kathryn has been employed by the pharmacy department at the Brigham and Women’s Hospital (BWH), Boston, Massachusetts, for the last several years.
Staff who process repeat prescriptions should be aware that this is acceptable although should still be brought to the doctors attention. Give message to the reception staff to ask patient to make appointment for Medication Review.
Explain that on this one occasion we will do them a favour but it still will involve a significant wait.
Specified period of time• Check last dose of medication given to patient.• Administer medication within 30 minutes of schedule. While large-scale technology upgrades can offer broad-based safety, there are also small-scale solutions to help reduce or eliminate IV medication errors and the adverse drug events (ADEs) they produce. Quite often, implementation of a large-scale IV medication safety network begins with smart infusion pumps. The practice should develop their own list of medicines which they feel are acceptable to be under-used. If any blood tests are required give clear message to the receptionist to book these prior to the review and note in consultation record which bloods are required. Patient Risk and Facility BurdenDue to the complex nature of IV medications, safe administration hinges not only on accurate physician prescribing, pharmacist review, and nursing administration, but also on proper preparation and monitoring. Smart pumps are effective in reducing IV medication errors and often rank as the highest priority in the integration of a safety system. However, trade names can vary from country to country and is often given by the company that makes that drug. While errors can occur for a variety of reasons and at varying points in the life of an IV medication, the most common point of error is during product preparation. Generally, the second highest priority is the incorporation of eMAR and BCMA systems, both of which electronically record all aspects of IV medication administration. In this example, the patient might ask for Zantac, but on their repeat prescription, it will be listed as Ranitidine. So, should a previous error go undetected or a new one be made, there is essentially no further opportunity to stop the IV preparation from affecting the patient. Depending on their severity, ADEs can cause temporary or permanent injury to the patient, require significant intervention to sustain life, and still may result in a patient’s death.
The primary concern for patient safety notwithstanding, ADEs also consume valuable resources, such as staff and patient time, and additional expenses directly proportional to the severity of the ADE. Among the available forms of IV drug delivery systems, each has characteristics, benefits, and issues that should be compared to a facility’s operational needs in order to determine compatibility (see Table 2).
Finally, ADEs compromise patient trust and are demoralizing to hospital staff.Barriers to Implementing Safer IV SystemsThere are several challenges that prevent the implementation of safer systems for intravenous medication use (see Table 1).
For example, ready-to-use parenteral medications can increase accuracy and safety, as well as streamline workflow by reducing the number of steps for IV preparation, while also reducing medication waste. Chief among these is a lack of standardization of and good process design for IV medication use.1 Many facilities use a wide variety of drug nomenclature, dosing units, dose limits, maximum infusion rates, weight limits, and volume limits within their facilities leading to obvious risk. For example, within IV smart pump libraries, there may be several different names listed for the same drug and each entry may list different dosage units.
For example, studying where, when, and by whom errors are being made can lead to the creation of special, targeted educational criteria to address areas of deficiency, as opposed to blanket re-education and re-training. Specific protocols that define procedures for drug administration, such as IV push versus slow infusion, provide helpful information to the bedside provider. Clinicians are prone to the belief that they do not make mistakes and perceive smart pump safety functions and dose guiding libraries to be cumbersome and an obstacle to efficient workflow. Prevention of ADEs can also be achieved by requiring an independent double check of doses and pump settings when calculations are required.



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