Using Innovative Technologies to Set New Safety Standards for the Infusion of Intravenous Medications

Abstract

Intravenous (IV) administration errors present a particularly challenging problem to hospital pharmacists. Current control systems intercept only 2% of drug administration errors causing preventable adverse drug events (PADEs).⁴ Estimated costs per preventable ADE are $4685 (1993 dollars). Of the most serious, life-threatening errors, 60% are associated with IV therapy. Conventional, general-purpose infusion devices cannot limit doses or easily be customized for specific patient populations. Clarian Health Partners, a 1400-bed health care system, consolidated infusion devices at three hospitals by implementing the MEDLEY Medication Safety System with Guardrails Safety Software. This new technology offers an innovative IV medication safety platform that functions at the point of care. Clarian became the first U.S. health care system to use this system on a hospital-wide basis. Development of a customized data set based on Clarian's best-practice guidelines was completed in 60 days, and installation at the 775-bed Methodist Hospital was completed in 3 hours. A potentially serious error was averted on the first day of system use. Initial data indicate that use of the IV medication safety system at Clarian's three hospitals will result in 4,000 events of reprogramming annually due to Guardrails alerts.

Keywords

adverse drug events infusion devices medication error prevention

Get full access to this article

View all access options for this article.

References

Committee on Quality of Health Care in America, Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, Eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

Gasch

Nursing shortfall is opportunity for companies serving the sector. BBI Newsletter. 2001; July: 155–60.

Bates

D.W.

, Cullen

D.J.

, Laird

Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE prevention study group. JAMA. 1995; 274: 29–34.

Leape

L.L.

, Bates

D.W.

, Cullen

D.J.

Systems analysis of adverse drug events. JAMA. 1995; 274: 35–43.

Bates

D.W.

, Spell

, Cullen

D.J.

The costs of adverse drug events in hospitalized patients. JAMA. 1997; 277: 307–11.

Kaushal

, Bates

D.W.

, Landrigan

Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285: 2114–20.

Ross

L.M.

, Wallace

, Paton

J.Y.

Medication errors in a paediatric teaching hospital in the UK: Five years operational experience. Arch Dis Child. 2000; 83: 492–7.

Hospital survey shows much more needs to be done to protect pediatric patients from medication errors. ISMP Medication Safety Alert! Huntington Valley, PA: Institute for Safe Medication Practices; April 19, 2000.

“Smart” infusion pumps join CPOE and bar coding as important ways to prevent medication errors. ISMP Medication Safety Alert! Huntington Valley, PA: Institute for Safe Medication Practices; February 6, 2002.