Establishing Countywide Safety Standards for HighRisk IV Medications

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Establishing Countywide Safety Standards for
High-RiskIV Medications

• Albert Rizos, PharmD
• Representing the SD Patient Safety Consortium
  Safe Administration of High-Risk IV Medications
  Task Force

Photo by Marc Balanky
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Introduction

• San Diego Patient Safety Consortium (SDPSC)
  evaluated areas for local patient safety
  improvements
• Standardization of IV infusion concentrations and
  dosage units was identified as a significant
  opportunity to reduce morbidity and mortality

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SDPSC Physician sponsor Joseph E. Scherger, MD,
MPH Clinical Professor and Director Quality
Improvement in Correctional Medicine Chair
Nancy Pratt, RN, MSN Vice President, Clinical
Effectiveness, Sharp HealthCare Special thanks
for meeting accommodations and coordination
to Tim Vanderveen, PharmD, MS, VP, Cardinal
Health Center for Medication Safety Erin Curtis,
Administrative Support, Cardinal Health Center
for Medication Safety
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The Case for IV Standardization

• IV meds e.g., heparin, insulin, morphine,
  propofol pose the highest risk of harm as the
  majority of harm reported involves IV drugs.1-3
• 61 of the most serious and life-threatening
  potential ADEs are IV drug-related.4
• IV administration often results in the most
  serious outcomes of medication errors.5

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The Case for IV Standardization

• Lack of standardization has been at least a
  partial cause of many individual cases of overly
  high doses, including a number of fatal
  overdoses.6,7
• Many nurses work in multiple settings, and
  unnecessary variability in standard
  concentrations of high-risk IV drugs creates
  unnecessary opportunities for potentially tragic
  errors.

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The Case for IV Standardization

• Bates et al reviewed infusion safety system (ie,
  smart pump) drug library data sets from more
  than 100 individual hospitals and found8
• An average of 64 drugs per data set and an
  average of 113 different drug/concentration
  combinations.
• An average of 4 different names per drug across
  the hospitals amiodarone had 45 different names.
• High variations in concentrations were
  ubiquitous 60 of medications had more than one
  continuous dosage unit (range, 19).
• For bolus dosing, 59 (50) of 199 drugs had more
  than one unit (range, 1-4).

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The Case for IV Standardization

• JCAHO NPSG 3b requires a hospital to
• 3. Improve the safety of using medications.
• 3b. Standardize and limit the number of drug
  concentrations used by the organization.

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Local Errors

• (Note RxIT system is shared by all SHC sites.
  Nursing IT system is not.)
• Labetalol ordered as 2 mg/min but IT system
  uses mg/hr dosage unit. Underdosed and patient
  required NTG drip to control BP. Need to
  standardize to mg/min units.
• Insulin ordered as 2 unit/hr, but delivered as
  0.5 unit/hr as pump was programmed with 2 ml/hr
  for concentration on 0.25 unit/ml. 4x error.
• Smart pumps may cross sites with different
  programmed standard concentrations, dosage units.
  

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Process

• Task Force selected 34 top meds, of which 9
  Hi-Risk
• Task Force developed standard survey tool to
  catalog all single-strength standards in use by
  all sites
• Researched manufacturers secondary tertiary
  references recommendations

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Process

• Iterative processreview survey results clarify
  responses prior to IV Task Force meetinghone
  evolving single standard to propose
• Task Force vote for final standards
• fist-to-five (no to total agreement)
• Commit to championing them at sites!!

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Variability Drug Concentrations and Dosing Units

• Concentrations
• 4 Different Conc Amiodarone, Fentanyl,
  Furosemide, Lorazepam, Magnesium (4 LVP, 6 IVPB)
• 3 Different Conc Dobutamine, Epinephrine,
  Labetalol, Lidocaine, Milrinone, Norepinephrine,
  Theophylline
• Dosing Units
• 4 Different Units Fentanyl
• 3 Different Units Furosemide, Theophylline

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Elimination of Non-standard ConcentrationsResult
s obtained across all participating hospitals by
the SDPSC
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Elimination of Non-standard Dosage UnitsResults
obtained across all participating hospitals by
the SDPSC
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Immediate Benefits

• Problem 4/06 JCAHO survey cited a participant
  hospital for not using a standard concentration
  for Abciximab (Reopro). Requested method would
  be very complex and error-prone.
• Resolution SDPSC community standard of practice
  was cited in defense of current method. Resolved
  by JCAHO reversal.

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Fate

• Hospital reps are responsible for promoting local
  adoption
• SHC has adopted the county standard concentration
  for Epi, and standard units for labetalol.
• SMH has adopted the county standard concentration
  for heparin and insulin, and standard units for
  Nipride.
• Re-survey participants after one year to assess
  degree of implementation

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SDPSC IV Standardization Toolkit

• This document is in the public domain and may be
  used and reprinted without permission provided
  appropriate reference is made to the San Diego
  Patient Safety Consortium. The information and
  tools in this document are also available in
  electronic format at www.cardinalhealth.com/clinic
  alcenter

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• References
• NCC MERP taxonomy of medication errors. National
  Coordinating Council for Medication Error
  Reporting and Prevention (NCC MERP). 1998.
• USP MedMarx, Analysis of Participating Hospital
  Data, 2001.
• Winterstein AG, Hatton RC, Gonzalez-Rothi R et
  al.. Identifying clinically significant
  preventable adverse drug events through a
  hospitals database of adverse drug reaction
  reports. Am J Health-Syst Pharm. 2002 59
  1742-9.
• Communication with D.W. Bates, M.D., M.Sc. of
  Brigham Women's Hospital in Boston, October
  2001.
• Hicks, RW, DD Cousins, RL Williams.  Summary of
  Information Submitted to MEDMARX in the Year
  2002. The Quest for Quality. Rockville, MD USP
  Center for the Advancement of Patient Safety,
  2003.
• Institute for Safe Medication Practices ISMP
  Medication Safety Alert! http//www.ismp.org/MSAa
  rticles/msa.html. Cited in Bates DW, Jt Comm J
  Pt Safety Qual. 200531(4)203-210.
• Schneider PJ. A review of the safety of
  intravenous drug delivery systems. Hosp Pharm.
  1999341044-56. Cited in Bates DW, Jt Comm J Pt
  Safety Qual. 200531(4)203-210.
• Bates DW, Vanderveen T, Seger DL, Yamaga CC,
  Rothschild J. Variability in intravenous
  medication practices implications for medication
  safety. Jt Comm J Pt Safety Qual.
  200531(4)203-210.

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• Thank you!