Stakeholders Seek to Prevent I.V. Medication Errors

Kate Traynor

Achieving fail-safe use of i.v. medications requires the creation and widespread use of standardized drug formulations, dosing units, and administration practices, a group of experts concluded during a two-day summit on i.v. medication safety.

Held July 14–15 at the United States Pharmacopoeia (USP) headquarters in Rockville, Maryland, the event brought together frontline physicians, nurses, and pharmacists, as well as health care executives, safety and regulatory experts, industry representatives, and others with a stake in improving i.v. medication safety.

"Errors with infused medications are frequent and frequently harmful to the point of death," ASHP Chief Executive Officer Henri Manasse Jr. told summit attendees. "We know that many within the health care community desire strong support to fix this problem and look for steadfast committments to take action."

USP's Medmarx drug-safety database contains nearly 4000 reports of harmful errors related to the use of parenterally administered medications, John Santell, USP's director of educational program initiatives, told summit attendees.

In this group of medications, morphine sulfate is the drug most frequently associated with harmful errors, followed by heparin and hydromorphone, he said. Of all classes of parenterally administered drugs, insulin is associated with the highest number of harmful errors, followed by opioid analgesics and anticoagulants.

The big question, Santell said, is "Why do we still see errors with these therapeutic categories after the many, many harmful events that have been reported?"

A major recommendation of summit attendees was that ASHP, USP, and the Institute for Safe Medication Practices (ISMP), within the next year, select at least 10 high-risk i.v. medications and create a standardized drug library for them.

The group recommended that the library be built from established drug databases and modeled after libraries that are programmed into so-called smart infusion pumps.

These libraries list standardized concentrations of i.v. solutions and their minimum and maximum dosages for specific patient populations, and pump users select each patient's medication regimen from the device's menu. When properly used, smart pumps can prevent certain programming errors, such as dosage miscalculations, misplaced decimal points, and inaccurate unit conversions.

Hospitals that adopt smart pumps must create for the devices a customized i.v. drug library that matches the organization's current practices. The library for high-risk drugs envisioned by the summit participants would be applicable to all settings where the drugs are used, whether or not smart pumps are in place.

Summit attendees also agreed that USP and ASHP should create overall standards for i.v. drug libraries and establish guidelines for the use of infused medications that are not amenable to inclusion in a standardized library.

The group agreed that a major obstacle to the safe use of i.v. medications is the preparation of admixtures outside of the pharmacy, a practice the attendees said should be minimized. Summit attendees recommended that health care professional associations develop a consensus statement within the next two or three years to address the issue.

The attendees concurred on the need to identify and refine best practices for the safe use of i.v. medications. ASHP Research and Education Foundation Chief Executive Officer Stephen J. Allen said the Foundation is interested in funding research in this area.

Safety barriers that arise from workplace culture need to be addressed, though the group acknowledged that this is a difficult and long-term goal. Specific issues that were raised during the meeting included the need to determine why hospital staff members deviate from established i.v. administration procedures and find institution-specific ways to minimize such deviations.

Also discussed was the lack of communication among groups within institutions and the need for an interdisciplinary approach to patient care that best uses the expertise specific to each member of the health care team. Attendees identified ways to tackle this problem—by teaching multidisciplinary care in the health professional schools and through continuing education, and by creating interdisciplinary medication safety committees in the workplace.

ASHP conceived of the summit more than a year ago and was joined by several other organizations—ISMP, USP, the ASHP Research and Education Foundation, the Infusion Nurses Society, the National Patient Safety Foundation, and the Joint Commission—to plan and convene the conference.

Summit attendees were selected with the goal of convening a good initial mix of stakeholders to start the preliminary work of improving i.v. medication safety. Subsequent work on the issue will involve a broader group of participants, said Bona Benjamin, director of medication-use quality improvement at ASHP.

Benjamin said she has received positive feedback from summit attendees and is "optimistic that needed changes will be achieved and sustained" through participants' efforts.

She credited the summit coconveners for their enthusiasm for the project.

"The collaborating organizations supplied the brain power," Benjamin said. "Without them, the work couldn't be done."

Full proceedings from the summit will be published in AJHP later this year. Additional information about the project and its ongoing work will be available online at www.ashp.org.

Baxter, Cardinal Health, and Hospira provided financial support for the project.