Healthcare Leaders Vow End to I.V. Medication Errors
Healthcare practitioners, thought leaders, and medication-safety experts met last week for an interdisciplinary summit convened by the American Society of Health-System Pharmacists (ASHP) to tackle the critical and urgent need for systems-based solutions to prevent the continuing patient death and harm caused by intravenous medication errors.
The ASHP I.V. Safety Summit brought together experts in medication safety and quality with frontline practitioners from around the nation to achieve consensus on an action agenda to make real and lasting improvements in the use of I.V. medications that would protect patients from harm and death due to errors.
“The recent heparin errors affecting infants in Indiana, California, and Texas serve as a tragic reminder that that immediate and significant steps are needed to protect the safety of patients receiving healthcare throughout the U.S.,” said ASHP CEO and Executive Vice President Henri R Manasse, Jr., Ph.D., Sc.D. “Patients need to know that their healthcare providers are passionate about safety and are working together to put an end to harm and death resulting from mistakes involving I.V. medications.”
The Summit was convened by several national healthcare organizations, including ASHP, the ASHP Research and Education Foundation, the United States Pharmacopeia, the Institute for Safe Medication Practices, the Infusion Nurses Society, the National Patient Safety Foundation, and The Joint Commission.
An expert panel, consisting of healthcare practitioners, safety experts, accrediting bodies, quality improvement organizations and federal regulators, evaluated current evidence on the incidence and causes of intravenous errors, including clinical issues, human factors, process design, technology, and effective methods of error prevention. The panel also engaged in a candid discussion about the need for culture change and the tension between maintaining safety while still providing care quickly and efficiently.
Summit participants proposed a number of strategies for achieving broad adoption of safe practices, including:
Standardizing product concentrations, patient care procedures, and equipment,
Developing toolkits and other resource materials to enhance the adoption of the recommendations, and
Improving mechanisms for communicating timely, actionable, and specific information about medication errors that can reduce the likelihood of similar events occurring elsewhere.
“This issue is deeply personal for each of the participants, which was clearly evident by the passion and energy of the group,” said Manasse. “It is clear that the entire healthcare community is committed to putting an end to these needless and heartbreaking events.
ASHP will move quickly to publish recommendations from the Summit in an effort to speed the pace of change and prevent further unnecessary deaths and injuries.
For more information about ASHP’s I.V. Safety Summit, and a full listing of the expert panel and other participants, visit www.ashp.org/iv-summit.
For more than 60 years, ASHP has helped pharmacists who practice in hospitals and health systems improve medication use and enhance patient safety. The Society's 35,000 members include pharmacists and pharmacy technicians who practice in inpatient, outpatient, home-care, and long-term-care settings, as well as pharmacy students. For more information about the wide array of ASHP activities and the many ways in which pharmacists help people make the best use of medicines, visit ASHP's Web site, www.ashp.org, or its consumer Web site, www.SafeMedication.com.
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