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Patient Safety Tip of the Week

August 4, 2020   Intravenous Issues

 

 

For some time we had been planning a column on issues related to various intravenous issues. A recent safety bulletin from ISMP Canada prompted us to do that column now.

 

ISMP Canada (ISMP Canada 2020) analyzed over 1500 incidents related to intravenous issues and found several underlying themes:

 

Handling and logistic challenges included subthemes: inappropriate timing, incompatibilities, incorrect labelling, and improper storage/expired product. Subthemes under administration errors included: wrong patient, wrong drug, wrong dose, wrong route, and wrong rate. Issues related to IV devices, supplies, or other equipment included pump programming issues, clamps, tubing, ­filters, and syringes. Also included were other issues, such as problems with batteries, printers, pump malfunction, and turning on/off.

 

While the majority of errors occurred during the administration stage of medication use (56.7%), errors also occurred during order entry/transcription (20.1%), and dispensing/delivery (14.5%). One in 10 incidents resulted in patient harm. The top 5 drugs in incidents causing patient harm were morphine, heparin, hydromorphone, piperacillin/tazobactam, and vancomycin.

 

Labeling issues often led to miscommunication. Calculations or instructions on the labels sometimes led to confusion with pump programming. For example, drug concentration or infusion rates on the MAR or on the infusion bag label often did not align with the pump programming units or sequence. One example was that calculation instructions for a pharmacy technician on the label were misread as programming information for the nurse.

 

Delays or miscommunication related to transport or portering of medication were also contributing factors

 

One very important theme that we’ve heard before from both ISMP Canada and ISMP US is over-reliance on technology, such as smart pump and bar-code technology (see our Patient Safety Tips of the Week for August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency” and June 11, 2019 “ISMP’s Grissinger on Overreliance on Technology”). The found that failure to perform an independent double check before IV medication administration (to verify and document the patient’s name, the drug and its concentration, the prescribed infusion rate, the line attachments and labels), was a key contributing factor in many of these incidents. We’ve discussed the pros and cons of double checks in many columns (listed below) but clearly there is a role for double checks, which should be done in a truly independent fashion, in medication safety.

 

One very interesting finding was the role of unfamiliarity with devices. That was especially a problem when inexperienced or relief staff were used. With infusion pumps, that may be related to the wide variety of pumps available on the market. The user interfaces might not be familiar to such staff. Programming sequences might differ or the metrics preprogrammed into the pumps might differ. Another problem with infusion pumps was that drug libraries or rates were sometimes incomplete. Our several prior columns on infusion pump problems are listed below.

 

Accessories were sometimes problematic. For example, a filter might be missing or correct tubing might not be available. Some items the ISMP Canada includes under “accessories” are not surprising to us, but others are surprising. One is pump failure due to inadequate maintenance and/or battery charge. Not surprising, given our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”. But they also identified one we had never thought about - printer-related issues, such as low ink levels resulting in illegible reports.

 

Problems with misidentification of IV lines continues to be a problem. ISMP Canada noted improper labelling of the IV line and transposition of IV lines after temporary disconnection as contributing factors. Our many columns on hazards of intrahospital transports, especially to the radiology suite, have emphasized the latter issue. Your “Ticket to Ride” checklist for intrahospital transports should highlight the need for accurate reconnection of any IV lines. So many of our patients today have multiple IV lines, so it is easy to mix them up. In addition to proper labeling of lines, many hospitals have used colored tags to help identify lines and their proper connections. One very interesting concept in the works is use of fiber optics to light up IV lines to facilitate correct identification (Vega 2019).

 

ISMP’s Michael Cohen (Cohen 2018) published an important article in 2018 about avoiding some common pitfalls in developing plans to reduce the likelihood of a recurrent incident. It happened to highlight cases of IV line transposition, in which a hospital suffered an IV line transposition accident, implemented what they thought was a solution, only to suffer a second similar accident within a few months.

 

In the index case, the patient “was receiving continuous IV infusions of octreotide and norepinephrine. Both infusions had been compounded by the pharmacy in 250-mL bags, so they were similar in size, and both were placed in brown overwraps to protect the medications from light, making them similar in appearance. They also had similar-looking pharmacy-applied labels on the overwraps. When the volume in both infusions was nearing completion, new infusion bags were hung simultaneously but were interchanged in error. The octreotide bag was spiked with the IV administration set that was loaded into the infusion pump programmed for norepinephrine, and the norepinephrine bag was spiked with the IV administration set that was loaded into the infusion pump programmed for octreotide. As a result, the patient received an overdose of norepinephrine and a subtherapeutic dose of octreotide.”

 

The hospital implemented what it felt were logical interventions to prevent a recurrence:

 

But, within a few months, a second very similar incident occurred despite those interventions. A cardiac patient was receiving continuous IV infusions of norepinephrine and EPINEPHrine. When new infusion bags were needed for both vasopressors after a procedure in the cardiac catheterization lab, a nurse (who was not involved in the prior event) inadvertently switched the 2 medications while replacing the bags. The IV lines had been labeled. However, the labels had been placed between the patient and the pump, not between the pump and infusion bag as required by the new policy. Because the labels were below the pumps, and the nurse had not traced the IV lines from the patient to the medication per policy, the nurse did not even notice the labels on the tubing. Like the previous error, both medications were similar in appearance, having been compounded by the pharmacy in 250-mL bags, placed in light-protective overwraps, and labeled with similar-looking pharmacy-applied labels.

 

Cohen pointed out that hospital relied too much on a process prone to human error (i.e. it stressed nurse vigilance as the primary action). That action plan also included a component (the barcoding piece) that would not be expected to have any effect on preventing a recurrent event. While such bedside barcoding is good practice to ensure the medication and the patient are correct, it does not prevent attaching the wrong medication to the wrong IV tubing. Perhaps most importantly, the hospital failed to address what was, arguably, the most important contributing factor: the IV bags were the same size and were wrapped in the same style overwrap, and labeled with similar-looking pharmacy-applied labels.

 

You should read the Cohen article for an excellent discussion on proper design and implementation of action steps following an untoward incident. We’ve just included it here because of its relevance to the issue of intravenous mistakes.

 

Kuitunen and colleagues did a series of articles earlier this year on hospital intravenous medication errors. In the first (Kuitunen 2020a) they did a systematic review of the literature on causes of such errors. Pretty much as you’d expect, they found systemic errors in all phases of the medication use process (prescribing, preparation, administration, dispensing and storage, and treatment monitoring. Administration, prescribing, and preparation were the process phases most prone to systemic errors. Leading causes were insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, calculation tasks, failure in double-checking procedures, and confusion between look-alike, sound-alike medications.

 

In the follow up article (Kuitunen 2020b) they looked at systemic defenses to prevent intravenous medication errors. In the literature they found features of closed-loop medication management systems appeared in 61% of the studies, with smart pumps being the defense most widely studied (24%). However, in general, the evidence quality of the included articles was limited and few were of high quality. Of the systemic defenses identified, 52% were related to administration, 18% prescribing, 13% preparation, 4% monitoring, and 2% dispensing.

 

Computerized orders and decision support systems were found to contribute toward safe dispensing, administration, and treatment monitoring by preventing errors related to interpretation of orders, calculation tasks, and follow-up. Other systemic defenses included prefilled syringes and color-coded systems, which were found to reduce errors in high-risk environments and situations, such as operating rooms and resuscitation.

 

The authors caution that, although smart infusion pumps were the systemic defense most widely studied, their effectiveness in preventing medication error remains unclear. They emphasize that the key component of smart pumps is the drug library containing predefined parameters for the drug type, strength, and dosing limits of specific drugs. They point out that “Soft” limits and alerts can be overridden by clinicians. Other problems include insufficient compliance in drug library use. Opportunities for improvement they cite include use of hard limits and integrating smart pumps with other systemic defenses, such as barcode readers and computerized physician order entry (CPOE), and real-time clinical data (e.g., glucose control and respiratory monitoring). They have a nice table that outlines error prevention components for each of the phases of the medication use system. Kuitunen and colleagues suggest that prevention of errors throughout the IV medication process requires integrating smart pumps into closed-loop medication management systems, such as electronic patient records, clinical pharmacist review of orders, automated compounding systems, barcode verification at the bedside, and real-time clinical monitoring data.

 

Flushing IV lines is always fraught with the risk that you might inadvertently use a dangerous solution to flush with. Most of you remember the series of disastrous incidents where high concentration heparin was used to flush lines (see our What's New in the Patient Safety World columns for December 2007 “1000-fold Heparin Overdoses Back in the News Again” and May 2008 “UK NPSA Alert on Heparin Flushes” and our July 15, 2008 Patient Safety Tip of the Week “Heparin Flushes.....Again!”). In our January 2020 What's New in the Patient Safety World column “ISMP Canada: Change Management to Prevent Recurrences” we discussed ISMP Canada’s simple, but practical, article on change management (ISMP Canada 2019). They described the steps taken by a hospital in response to two fatal pediatric incidents involving concentrated potassium solutions. One of those incidents involved the inadvertent use of concentrated potassium phosphate solution to flush an intravenous line.

 

One category of errors is the inadvertent intravenous administration of medications or substances that were intended for use via another route. The corollary is inappropriate administration in another route of a medication or substance that was intended to be administered intravenously. Each is usually met with disastrous consequences. We’ve done several columns on vincristine administered intrathecally rather than intravenously:

    December 2016 “Standardize 4 Safety and Just Bag It!”

    June 2017 “Just Bag It Campaign Success Story”

    January 2018 “Eliminating Vincristine Administration Events”

    June 12, 2018 “Adverse Events in Cancer Patients”

The Just Bag It! campaign calls for health care professionals to always dilute vincristine in a 50ml mini-IV drip bag and never in a syringe to minimize the risk of such incidents. We’ve also done columns on inadvertent spinal injection of tranexamic acid (see our Patient Safety Tips of the Week for June 4, 2019 “Medication Errors in the OR – Part 3” and July 9, 2019 “Spinal Injection of Tranexamic Acid”).

 

And it is not just drugs intended for spinal use that might get injected intravenously. A recent AHRQ Web M&M described cases where solutions intended for bladder irrigation were instead hooked up to patients’ intravenous lines (Bohringer 2020). It is recommended that irrigation fluids should be clearly labelled as “For Irrigation Only” and the label should be made in a bright noticeable color. “This label should also be large and ideally cover about a third of the size of the fluid bag. The label should be attached to the bag of fluid as soon as an additive has been injected because this additive now has effectively converted the bag of intravenous fluids into an irrigation solution. Irrigation solutions should not be stored in the same location as intravenous fluids once they have been prepared. Consideration should be given for irrigation solutions to be prepared in pharmacy and appropriately labelled there.”

 

Intravenous fluids and irrigation fluids should ideally not be suspended together from the same IV pole. Intravenous and irrigation fluid bags should always be spiked with their respective tubing right after they are hung on the pole. It should be easy to visually distinguish the irrigation tubing from the IV tubing. Irrigation specific tubing and connectors should be employed whenever available. Designating a pole for exclusive use with irrigation fluid also has been described as a useful strategy to prevent this type of error.1 Hanging bags of fluid from poles when they are not connected to any tubing is bad practice and should be avoided.

 

Bohringer also encourages industry to develop bags and tubing of different colors for irrigation solutions in the same way that they have developed yellow tubing to clearly distinguish epidural infusion lines from intravenous lines.

Most intravenous medications are administered via infusion, but some are administered by a “push” or bolus. ISMP in 2015 issued “Safe Practice Guidelines for Adult IV Push Medications” (ISMP 2015). But those guidelines are not always adhered to. A follow up survey in 2018 (ISMP 2018) showed numerous risky practices associated with the administration of IV push medications continued. These included the withdrawal of medications from prefilled syringes or cartridges, unnecessary dilution of IV push medications, and nurse preparation or manipulation of IV push medications at the bedside. Although the 2018 survey showed a reduction in some of these unsafe practices, many practitioners still reported using prefilled syringes or cartridges as vials, diluting IV push medications despite their availability in a ready-to-administer form, unsafe labeling practices, and preparing IV medications at the bedside. These were not always just due to human error alone. Other factors contributing to them included Some of these unsafe practices appear to be associated with ongoing drug shortages, system vulnerabilities, and/or teaching strategies that perpetuate these practices.

 

Withdrawing medications from a prefilled syringe (or cartridge) and transferring into another syringe to administer some or all of an IV push medication dose is considered an unsafe practice. Yet 66% of respondents reported withdrawing medications from a prefilled syringe (or cartridge) and transferring into another syringe to administer some or all of an IV push medication dose, and 16% do this more than half of the time they encounter a prefilled syringe.

 

As many as 1 in every 5 participants still reported in 2018 that they sometimes, often, or always dilute medications provided in multiple-dose vials (21%) or manufacturer’s prefilled syringes (16%), another practice considered unsafe. Opioids, anxiolytics/antipsychotics, and antiemetics were the most frequently diluted medications. Such dilution was often carried out using a prefilled saline flush syringe and seldom was that included on the label of the final product.

 

Labeling was another issue. Only half the participants always label IV push medications that are self-prepared away from the patient’s bedside. This sometimes results in a nurse carrying multiple unlabeled syringes at one time.

 

Training plays a role in perpetuation of some unsafe practices. Most respondents were taught how to administer IV push medications earlier in their career or current position, often being told to dilute the IV push medications.

 

The rate of administration of a drug may be very important from a safety perspective. But that rate is not always provided on the patient’s medication administration record or electronic health record. Some respondents said they need to look up the rate of administration in drug references (41%), in facility-specific guidelines (40%), or remember the rate from previous administrations (41%), and 18% said they administer all IV push medications over 2 to 5 minutes, so they don’t need to look up or know the specific rate of administration for each drug. To control how fast they are administering IV push medications, 82% use a clock, watch, phone, or other timing device. To administer the dose over the desired timeframe, 38% stated that they give small incremental doses frequently, whereas 30% said they just apply constant pressure on the plunger. In our March 2017 What's New in the Patient Safety World column “Loading Doses Again” we discussed how the recommended rates of administration of loading doses of phenytoin or fosphenytoin are often not adhered to, resulting in adverse cardiac effects.

 

Lastly, there is one type of chemotherapy adverse event we consider unforgivable. That is when a chemotherapy drug intended to be infused over several days gets infused much more rapidly (see our Patient Safety Tips of the Week for September 11, 2007 “Root Cause Analysis of Chemotherapy Overdose”, April 6, 2010 “Cancer Chemotherapy Accidents”, September 15, 2015 “Another Possible Good Use of a Checklist”, and June 12, 2018 “Adverse Events in Cancer Patients”). In those columns on home infusion chemotherapy we noted no one seems to be asking “what is the highest dose that a patient could tolerate in one day (or less) if there was inadvertent administration of the whole infusion?”. A safety culture would design the protocol with sublethal dosages that would protect the patient in the event of “what can go wrong will go wrong”. It also would not put the healthcare workers at the “sharp end” in a situation none of us would want to be in. Why would you ever expose a patient to the risk of a fatal overdose just for the sake of convenience of the patient, healthcare professional or payer?

 

 

Some of our other columns on medication errors:

 

December 2007           “1000-fold Heparin Overdoses Back in the News Again”

May 2008                    “UK NPSA Alert on Heparin Flushes”

July 15, 2008              “Heparin Flushes.....Again!”

March 24, 2009           “Medication Errors in the OR”

May 20, 2014              “Ophthalmology: Blue Dye Mixup”

September 2014          “Another Blue Dye Eye Mixup”

November 3, 2015      “Medication Errors in the OR - Part 2”

December 1, 2015       “TALLman Lettering: Does It Work?”

May 2016                    “Name Confusion in the Pharmacy”

May 24, 2016              “Texting Orders – Is It Really Safe?”

July 2016                    “ISMP Updates TALLman Lettering List”

August 23, 2016         “ISMP Canada: Automation Bias and Automation Complacency”

December 2016           “Standardize 4 Safety and Just Bag It!”

March 2017                 “Loading Doses Again”

March 2017                 “Yes! Another Voice for Medication e-Discontinuation!”

June 2017                    “Just Bag It Campaign Success Story”

August 2017               “Medication Errors Outside of Healthcare Facilities”

September 2017          “Safe Medication Use in the ICU”

January 2018               “Eliminating Vincristine Administration Events”

February 2018             “10 Years on the Wrong Medication”

May 8, 2018                “Heparin Overdose”

August 28, 2018         “Thought You Discontinued That Medication? Think Again”

September 2018          “ISMP Updates List of High-Alert Medications”

December 4, 2018       “Don’t Use Syringes for Topical Products”

December 11, 2018     “Another NMBA Accident”

December 18, 2018     “Great Recommendations for e-Prescribing”

January 1, 2019           “More on Automated Dispensing Cabinet (ADC) Safety”

February 5, 2019         “Flaws in Our Medication Safety Technologies”

February 12, 2019       “From Tragedy to Travesty of Justice”

March 5, 2019             “Infusion Pump Problems”

April 2019                   “ISMP on Designing Effective Warnings”

June 11, 2019              “ISMP’s Grissinger on Overreliance on Technology”

July 9, 2019                “Spinal Injection of Tranexamic Acid”

August 2019               “Including Indications for Medications: We Are Failing”

August 6, 2019           “Repeat Adverse Drug Events”

November 19, 2019    “An Astonishing Gap in Medication Safety”

February 4, 2020         “Drugs and Chronic Kidney Disease”

May 2020                    “PPSA on IV Vancomycin Safety”

June 16, 2020              “Tracking Technologies”

July 2020                    “Medication Dosage Miscalculations”

July 21, 2020              “Is This Patient Allergic to Penicillin?”

 

 

Some of our prior columns on medication errors in the OR:

 

March 24, 2009           “Medication Errors in the OR”

May 20, 2014              “Ophthalmology: Blue Dye Mixup”

September 2014          “Another Blue Dye Eye Mixup”

November 3, 2015      “Medication Errors in the OR - Part 2”

June 4, 2019                “Medication Errors in the OR – Part 3”

July 9, 2019                “Spinal Injection of Tranexamic Acid”

June 9, 2020                “Perioperative Medication Safety”

June 16, 2020              “Tracking Technologies”

 

 

Our prior columns related to infusion pump issues:

 

Some of our other columns on double checks:

 

January 2010               “ISMP Article on Double Checks”

October 26, 2010        “Confirming Medications During Anesthesia”

October 16, 2012        “What is the Evidence on Double Checks?”

December 9, 2014       “More Trouble with NMBA’s”

April 19, 2016             “Independent Double Checks and Oral Chemotherapy”

December 11, 2018     “Another NMBA Accident”

March 5, 2019             “Infusion Pump Problems”

August 27, 2019         “Double Check on Double Checks”

 

Some of our prior columns on vincristine administered intrathecally rather than intravenously:

 

December 2016           “Standardize 4 Safety and Just Bag It!”

June 2017                    “Just Bag It Campaign Success Story”

January 2018               “Eliminating Vincristine Administration Events”

June 12, 2018              “Adverse Events in Cancer Patients”

 

 

Some of our prior columns on medications administered intravenously rather than spinally or spinally rather than intravenously:

 

April 2010                   “RCA: Epidural Solution Infused Intravenously”

December 2016           “Standardize 4 Safety and Just Bag It!”

June 2017                    “Just Bag It Campaign Success Story”

January 2018               “Eliminating Vincristine Administration Events”

June 12, 2018              “Adverse Events in Cancer Patients”

July 9, 2019                “Spinal Injection of Tranexamic Acid”

 

 

 

 

References:

 

 

ISMP Canada. Intravenous Medication Safety: A Multi-Incident Analysis. ISMP Canada Safety Bulletin 2020; 20(7):  1-4 July 16, 2020

https://www.ismp-canada.org/download/safetyBulletins/2020/ISMPCSB2020-i7-IVMedsAnalysis.pdf

 

 

Vega M. This Healthcare Startup Lights Up IV Lines to Cut Out Human Error. Hypepotamus.com 2019; April 8, 2019

https://hypepotamus.com/companies/lightengale/

 

 

Cohen MR. Common Missteps with Medication Safety: Rolling a Single Dice, Ineffective Strategies, and Unexecuted Action Plans. Hospital Pharmacy 2018, 53(1): 25-28

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805021/pdf/10.1177_0018578717747445.pdf

 

 

Kuitunen S, Niittynen I, Airaksinen M, Holmstrφm A-R. Systemic Causes of In-Hospital Intravenous Medication Errors. A Systematic Review. Journal of Patient Safety 2020; Publish Ahead of Print January 31, 2020

https://journals.lww.com/journalpatientsafety/Abstract/publishahead/Systemic_Causes_of_In_Hospital_Intravenous.99231.aspx

 

 

Kuitunen SK, Niittynen I, Airaksinen M, Holmstrφm A-R. Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals, Journal of Patient Safety 2020;: Publish Ahead of Print March 14, 2020

https://journals.lww.com/journalpatientsafety/Abstract/9000/Systemic_Defenses_to_Prevent_Intravenous.99194.aspx

 

 

ISMP Canada. Change Management in Response to Preventable Tragedies. ISMP Canada Safety Bulletin 2019; 19(10): 1-5 December 12, 2019

https://www.ismp-canada.org/download/safetyBulletins/2019/ISMPCSB2019-i10-ChangeManagement.pdf

 

 

Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. AHRQ PSNet WebM&M 2020; March 2020

https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room

 

 

ISMP (Institute for Safe Medication Practices). ISMP Safe Practice Guidelines for Adult IV Push Medications; ISMP 2015

https://www.ismp.org/guidelines/iv-push

 

 

 

ISMP (Institute for Safe Medication Practices). Part I: Survey Results Show Unsafe Practices Persist with IV Push Medications. ISMP Medication Safety Alert! Acute Care Edition 2018; 23(22): November 1, 2018

https://www.ismp.org/resources/part-i-survey-results-show-unsafe-practices-persist-iv-push-medications

 

 

 

 

 

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