Preventable Medication Errors Shouldn’t Happen
By Ivyruth Andreica, Clinical and Medication Safety Pharmacist
When it comes to preventing medical errors, medication matters—a lot. Industry watchdog The Leapfrog Group recently added medication errors to its biannual hospital grading system because they are a significant cause of patient safety events. IV medication issues, in particular, frequently appear on ECRI’s annual list of the Top 10 Health Technology Hazards. For 2019, infusion confusion—mixing up dose rate and flow rate when setting up infusions—made the recently released annual list. In fact, studies show that 54% of adverse drug events involve infusion errors—many due to mis-programming of the pump.
But this doesn’t have to be the case. Can healthcare professionals—and pharmacists, in particular—do more to advocate for infusion safety?
Did you know that physician infusion orders—verified by pharmacists—can be directly transmitted to smart pumps for auto-programming, ensuring that the right drug in the right dose is administered to every patient? Those of us who are technically inclined may be aware that this can be accomplished through a combination of computerized physician order entry (CPOE), bar code assisted medication administration (BCMA) and bi-directional communication with pumps. However, anyone involved with infusion delivery will immediately recognize the tremendous benefits that the elimination of manual programming will have on minimizing human error and boosting patient safety.
While CPOE, BCMA and smart pumps are commonplace in hospitals today, according to the 2017 KLAS report, only 200 U.S. hospitals (~4%) have the integration that will support auto-programming in place. The major barriers to integration are the high cost, complexity and overall staff resources required.
Unfortunately, many hospitals continue to rely on dose error reduction systems (DERS) alone as a key line of defense against IV errors. And the reality is that clinicians continue to override these systems with frequency. Moreover, not all hospitals even have a DERS implementation.
Pharmacists are also keenly aware of another common issue contributing to IV drug delivery errors—out-of-date drug libraries. A recent two-year study evaluating 12 health systems found that 11 had library update delays ranging from three weeks to six months. As a result, clinicians were forced to deliver infusions using outdated parameters and unknowingly placed patients at risk.
Auto-programming can help organizations tackle a full gamut of medication errors, including potentially lethal mistakes such as mix-ups between IV and epidural routes. Recently, the Institute for Safe Medication Practices (ISMP) published an error involving a pregnant woman administered bupivacaine intravenously, which can be fatal. Pump auto-programming would have prevented an infusion set up in the manner from even starting. A DERS, however, would not.
This spring, ISMP convened leading healthcare experts to discuss and update its 2009 smart pump safety guidelines. Participants were extremely vocal about their support for infusion pump auto-programming. One of the ISMP’s strongest and possibly failsafe recommendations to avoid serious IV medication delivery errors was implementing the integrated smart pump platform that would automate physician order programming directly into pumps across all care areas. It is clearly evident that they believe a patient’s safety far outweighs the barriers of implementation.
As pharmacists, regardless of our specialties, we are constantly focused on ensuring the right drug is administered in the right dose to the right patient. At this year’s American Society of Health-System Pharmacists (ASHP) midyear meeting in Anaheim—the world’s largest gathering in the pharmacy field—medication safety was on everyone’s minds. The statistics and events cited above have once again put medication safety, and IV medication safety in particular, in the spotlight—as well they should.
Pharmacists are highly appropriate to champion smart pump auto-programming to ensure the drug delivery they oversee is error-free. Nurses too play an important role because the integration will alter their workflow, and they will have to be open to changing and adjusting.
Can we truly say that we are putting patients first when the technology exists to prevent medication errors and hospitals fail to put it to work?
Ivyruth Andreica is the Clinical & Medication Safety Pharmacist at Ivenix. Ivy specializes in medication safety and has over 7 years experience in clinical pharmacy. As a pharmacist as well as critical care nurse, Ivy is uniquely qualified to provide a well-rounded perspective of safe and effective IV administration.