Announcment
At the 2009 Midyear Clinical Meeting, ASHP announced the launch of the National Alert Network (NAN), a system to rapidly share information on serious medication errors among the healthcare community. Alerts are currently distributed to ASHP members, ISMP subscribers, and participants of the IVSS. A sign-up system for nonmembers is under development. Read press release
What's New
Summit Topics
About the Summit
On July 14 and 15, ASHP and its partners gathered healthcare practitioners, thought leaders and medication-safety experts from around the nation to achieve consensus on actions that will bring about real and lasting improvements in the use of IV medications, protecting patients from harm and death due to errors.
Background
Although much has been published on the nature and causes of intravenous medication errors and successful preventive strategies, this information has not resulted in widespread implementation by the medical and allied health professions, hospital and health-system leadership, the pharmaceutical industry, or regulatory and standards-setting organizations. Serious errors continue to occur.
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The American Society of Health-System Pharmacists, along with the American Society of Health-System Pharmacists Research and Education Foundation, Institute for Safe Medication Practices, United States Pharmacopoeia, Infusion Nurses Society, National Patient Safety Foundation and The Joint Commission, will co-convene an expert panel to examine the issue of death or serious injury resulting from errors with intravenous medications.
The purpose of the Summit is to initiate actions that bring about sustainable changes in intravenous medication-use system and prevent further death or harm from errors.
Rationale
Health care safety experts and researchers have documented an unacceptably high incidence of harm and death from medical errors in general, most notably in the Quality Chasm series of reports from the Institute of Medicine (IOM). These and other studies characterize medical error as a pervasive symptom of the current health care system's inability to deliver care safely and effectively. Medication errors account for a significant proportion of these events and frequently cause patient harm and sometimes death. Errors associated with the use of parenteral medications are more likely to result in serious patient injury or death.
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In general, errors with "high alert" or "high risk" parenteral drug products have the most potential for harm because of their immediate and profound physiologic effects and are the most visible. Serious or fatal errors have been associated with inadvertently using the incorrect concentration of these agents or administering them via the incorrect route. Recent neonate deaths in Indiana were caused by a mix-up between heparin 10,000 units/ml and 10 units/ml (Washington Post, September 18, 2006). These and other more recent errors are a tragic reminder of serious flaws that exist in systems intended to ensure safe handling of intravenous medications.
Effective error prevention strategies are well-known and widely promoted by safety organizations. However among hospitals and health systems, practices vary widely from setting to setting, are not always followed, and do not consistently protect patients from error. In order to accomplish the goal of sustainable change to prevent error, participants in the IV Safety Summit will asked to provide insight on critical aspects of intravenous medication use that need to be addressed for change to occur.
Expert Panel
An expert panel, consisting of frontline practitioners, safety experts, and oversight groups, will consider current evidence on the incidence and causes of intravenous errors, clinical issues, human factors, process design, technology, and effective methods of error prevention. The panel will contribute perspectives from their practice experiences and positions of oversight in medication safety, medication use standards-setting and regulatory issues.
See expert panel list [PDF]
Panel Discussion Points
The charge of the expert panel is to consider the following questions related to safe use of intravenous medications:
- What are the problems? What are the solutions?
Answer
The panel will evaluate failure points in the medication use system and determine the essential practices that are most likely to prevent harm or death from intravenous medication use based on the following criteria:
- Generalizable to a variety of settings, achievable, and likely to significantly improve safety,
- Address problem-prone or high risk aspects of IV medication use,
- Specific as to required action(s) and accountability
- Supported by research, expert consensus, or experiential data, and
- Provide practitioners with a framework for assessing and improving IV medication use safety.
- Why are practices agreed to be effective not universally used?
Answer
The panel and workgroups formed from invited stakeholders will identify barriers to implementation of the selected practices.
- What actions are needed to bring about a sustainable change that prevents further harm and death from intravenous medication errors?
Answer
The panel and workgroups formed from invited stakeholders will recommend strategies for overcoming barriers to implementing the essential practices. The panel will also recommend next steps for physicians, nurses, pharmacists and pharmacy technicians, industry, regulatory agencies, accreditation bodies, standards-setting groups, safety organizations, and other identified stakeholders. Such steps might include recommendations for further areas for research and initiatives to address issues specific to stakeholder groups.
- How will improvement be measured?
Answer
The panel will identify goals or milestones that indicate that changes critical to success have occurred.
Summit Goals
- Achieve consensus on an initial set of broadly applicable standard practices and methods that are effective in preventing patient harm or death associated with the use of intravenous medications.
- Identify barriers to adoption or implementation of the practices and recommend specific actions to overcome them. Practices will be prioritized into an essential core group for immediate implementation and those requiring a phased-in approach.
- Identify areas for future research and issues that are specific to and should be resolved by various stakeholder groups
Co-Conveners
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