ASHP strategies endorsed by pharmacists

September 15, 2008

The ASHP IV Safety Summit convened a panel of experts to explore ways to combat errors in use of IV medications.

Key Points

Intravenous (IV) medication errors are responsible for serious harm and death to patients in virtually every hospital across the country. Recently, the American Society of Health-System Pharmacists (ASHP) convened a summit to explore how health-care practitioners can combat errors associated with IV medications.

Among the goals of the ASHP IV Safety Summit was to achieve consensus on an action agenda to make significant and lasting improvements in the use of IV medications that would protect patients from harm and death.

ASHP, in conjunction with the United States Pharmacopeia (USP), the Institute for Safe Medication Practices (ISMP), the Infusion Nurses Society, the National Patient Safety Foundation, and The Joint Commission, assembled a panel of experts who evaluated evidence on the incidence and causes of IV errors, including clinical issues, human factors, process design, technology, and effective methods of error prevention.

"One of the things about sterile products is you can look at the bag and you'll never know what's in it once it's prepared," William Gouveia, RPh, a consultant in the pharmacy department at Tufts Medical Center in Boston, said. Gouveia, the former director of pharmacy at Tufts, said that, unlike oral medications that are more easily identifiable, IV products go from "prep to vein" and there is no easy way to analyze them short of sending them out to a lab for analysis. "You need control and documentation, and there needs to be a very rigorous IV pedigree so that you know what goes in point A, and point B, and point C. And clearly, buying as much premanufactured product as you can is ideal."

Richard Paoletti, RPh, director of pharmacy at Lancaster General Hospital in Lancaster, Pa., said that IV medications are complex therapies that have the greatest risk potential and can produce a fair amount of harm to patients - including death. "A multidisciplinary approach focused on the entire medication-use process for these agents is long overdue," he said.

Gouveia endorses the panel's proposal regarding standardization, which includes the use of smart pumps. Gouveia pointed out that smart pumps had a "tricky introduction" with several of the top-tier brands encountering problems. The idea of toolkits and resource material also received kudos from Gouveia, a veteran health-system pharmacist. "Providing educational materials such as CDs, brochures, charts, and graphs to the staff and training and educating them about the new standards and systems is another key ingredient in reducing errors."

Health-system pharmacists also support adoption of Failure Mode Effect Analysis (FMEA) and root-cause analysis strategies that allow institutions to document where in the organization there are issues and problems and how the results of those analysis can be communicated to the staff. "Hopefully, in a learning environment we can discuss how we can do things differently. Is it a matter of staff training? Is it a manufacturer issue? And bring that all down to the patient level," Gouveia said. Paoletti told Drug Topics that focusing on high-alert medications, standardizing concentrations, and formulating drug libraries for intelligent infusion pumps are all worthwhile activities. "Having a standard set of guidelines and/or position statements including educational material will be very helpful to many hospitals."

Gouveia said that he would like to see this type of summit convene every two years or even annually. "I think there needs to be a continuing consensus about how we reduce these terrible errors, they continue to occur."

ANTHONY VECCHIONE is a health and medical writer based in New Jersey.