IV drug errors highlight need for universal standards

January 1, 2009

The annual summit of the American Society of Health-System Pharmacists called for ways to reduce drug errors. The need for universal IV concentrations is primary. "Safety will improve dramatically if we all work with the same tools." (Peter Angood, Joint Commission)

Key Points

Universal standards for intravenous drug concentrations should be the next big change in hospital practice. That's the leading recommendation from a summit on reducing IV-related drug errors convened by the American Society of Health-System Pharmacists in 2008. Proceedings of the summit and an action plan were released in mid-December.

"The number one priority is to standardize IV infusion concentrations across all settings," said Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission. "Safety will improve dramatically if we all work with the same tools. This is a difficult step, but the potential safety gain is highly significant."

Angood spoke at a press conference that launched ASHP's campaign to change the way IV medications are approved, packaged, delivered, administered, and monitored. Co-sponsors included the US Pharmacopeia, the Institute for Safe Medication Practices, the Infusion Nurses Society, the National Patient Safety Foundation, and The Joint Commission.

IV medications were responsible for 12.5 percent of all adverse events reported to MEDMARX between 2002 and 2006, Manasse said. In comparison with other medications, IV drugs are twice as likely to harm patients.

More than 40 percent of all IV drug errors that result in patient harm involve opioids, insulin, or anticoagulants, he said. The most common errors are wrong administration technique, wrong drug, or wrong route of administration.

"All of these errors are preventable," Manasse said. "There are essential safe practices that every caregiver and every institution should follow."

The Joint Commission already requires hospitals to limit and standardize drug concentrations as part of the accreditation process, Angood said. The next step is to expand standardization across the entire continuum of care. Some IV medications are available in as many as 18 different concentrations, said Diane Cousins, who represented the US Pharmacopeia Center for Advancement of Patient Safety. Drug concentrations and dosing strategies vary widely between healthcare settings.

Concentrations and strategies can also change dramatically between departments within the same institution. Every change in standard procedures increases the likelihood of adverse events as patients move between care settings. Implementation of universal standards for drug concentrations and dose ranges is one of more than 40 essential practices the summit identified across all levels of the IV medication process.

"Many groups have looked at medication errors, but this summit represented the full spectrum of disciplines and professions, from nurses to pharmacists, physicians, and bioengineers," said Justine Medina, director of professional practice and programs, American Association of Critical-Care Nurses. "When an error occurs, it is a fault of the system, not an individual."

Common problems include infusion pumps that are not intuitive or that allow users to disable alarms, as well as different programming systems used by different equipment manufacturers.

Look-alike, sound-alike product names are another common problem, she added. Drugs such as dopamine and dobutamine are all too easy to confuse. IV compounding is another common source of error. Allen Vaida, executive vice president, Institute for Safe Medication Practices, noted that reducing compounding and product manipulation also reduces medication errors. He called on manufacturers to deliver a better range of ready-to-use concentrations, especially for high-alert medications that are most likely to cause patient harm. If IVs must be compounded, the work should be done in pharmacy by trained pharmacy personnel, Vaida said. Centralizing compounding in a single department increases safety by using more highly trained personnel and more automated technology. The goal is to deliver ready-to-use doses.