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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
- Administration errors
- Issues related to IV devices, supplies, or other equipment
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.
Delays or miscommunication related to transport or portering of medication were also contributing factors
One very important theme that weve 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 ISMPs Grissinger on Overreliance on Technology). The found that failure to perform an independent double check before IV medication administration (to verify and document the patients 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. Weve 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).
ISMPs 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.
The hospital implemented what it felt were logical interventions to prevent a recurrence:
- Label all infusion lines between the pump and the infusion bag so the label is visible during bag changes
- Trace all infusion lines from the patient, through the pump, and to the medication to verify the correct route of administration, pump, and line prior to starting an infusion or changing the bag
- Use the existing barcode point-of-care (BPOC) system to scan each infusion at the bedside prior to set-up and administration (previous practice had been to pre-scan the infusions upon receipt from the pharmacy).
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. Weve 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 youd 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 Canadas 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. Weve 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. Weve 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.
Labeling was another issue. Only half the
participants always label IV push medications that are self-prepared away
from the patients 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 patients 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 dont 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 Dont
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 ISMPs 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:
- May 2010 FDA's Infusion Pump Safety Initiative
- April 27, 2010 Infusion Pump Safety
- August 2016 Home Infusion Therapy Pitfalls
- March 5, 2019 Infusion Pump Problems
- March 2020 ISMP Smart Infusion Pump Guidelines
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 NMBAs
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
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
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
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