Implementation of an i.v. medication safety system

Abstract

The medication-use process is extremely complex and involves multiple steps performed by people in conjunction with machines, and medication errors can occur in any step of this process. Medication errors associated with high-risk drugs have the greatest potential to cause significant patient harm. Many high-risk-of-harm drugs1–,3 (e.g., heparin, insulin, opioids) can be delivered by i.v. infusion, and administration is the step most vulnerable to error.4 Prevention of i.v. medication administration errors at the point of care, particularly those involving continuous-drug-infusion programming errors, should be a primary focus to prevent patient harm. The use of technology is essential for changing the medication-use system and enabling clinicians to avoid errors. Some computerized prescriber-order-entry (CPOE) systems have dose limits that pharmacists can develop to help ensure the safety of prescribed dosages. The use of bar-code medication verification can help ensure the “five rights.” However, neither technology can safeguard patients against i.v. infusion programming errors.5 The introduction of an i.v. medication safety system (a computerized i.v. infusion system with hospital-defined drug libraries with dose limits) can help safeguard patients and caregivers against i.v. administration errors. This system can also provide previously unavailable data on the frequency and characteristics of high-risk medication errors averted by its use.

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