Drug Topics - January 2009 - (Page H7) REDUCING IV-RELATED DRUG ERRORS HSE I Clinical IV summit calls for universal concentration standards FRED GEBHART, Contributing Editor U niversal 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. “We see on an ongoing basis incidents of harm from IV medications,” said ASHP Executive Vice President and CEO Henri Manasse, Jr. “Errors tend to be the same errors repeated time and again. We don’t want any more harm, any more deaths, from these medications.” IV medications were responsible for 12.5 percent of all adverse events reported to MEDMARX between 2002 and 2006, Manasse said. In comparison Network Clinical SEE INDEX PAGE 10 For more info on this topic, see www.drugtopics.com 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, Other key practices include: Delivery of IV products to the point of care in a form that requires no further dilution or other manipulation Use of intelligent pumps and other automation whenever possible, with standardized, machine-readable bar codes on every IV dose Establishment of shared responsibility for patient safety among all members of the care team Making the business case for IV safety to hospital leadership Creation of multidisciplinary medication safety committees in every hospital 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. “All IV medications should be available to the individual user in a form that does not have to be manipulated,” he said. “That includes doses intended for patients, for nurses, and for home use. We need to make sure that FDA and manufacturers work together.” DRUG TOPICS W W W.D R U GTO P I C S .C O M Januar y 2009 H7 http://www.drugtopics.com http://WWW.DRUGTOPICS.COM
Table of Contents Feed for the Digital Edition of Drug Topics - January 2009 Drug Topics - January 2009 Contents Letters Up Front Up Front in Depth Community Practice Drug Pipeline: What to Watch in 2009 OTC Community-Aquired MRSA Infections New Products Viewpoint Drug Topics - January 2009 Drug Topics - January 2009 - Drug Topics - January 2009 (Page Cover1) Drug Topics - January 2009 - Drug Topics - January 2009 (Page Cover2) Drug Topics - January 2009 - Drug Topics - January 2009 (Page 1) Drug Topics - January 2009 - Drug Topics - January 2009 (Page 2) Drug Topics - January 2009 - Drug Topics - January 2009 (Page 3) Drug Topics - January 2009 - Contents (Page 4) Drug Topics - January 2009 - Contents (Page 5) Drug Topics - January 2009 - Contents (Page 6) Drug Topics - January 2009 - Contents (Page 7) Drug Topics - January 2009 - Contents (Page 8) Drug Topics - January 2009 - Contents (Page 9) Drug Topics - January 2009 - Contents (Page 10) Drug Topics - January 2009 - Contents (Page H1) Drug Topics - January 2009 - Contents (Page H2) Drug Topics - January 2009 - Contents (Page H1) Drug Topics - January 2009 - Contents (Page H2) Drug Topics - January 2009 - Contents (Page H3) Drug Topics - January 2009 - Contents (Page H4) Drug Topics - January 2009 - Contents (Page H5) Drug Topics - January 2009 - Contents (Page H6) Drug Topics - January 2009 - Contents (Page H7) Drug Topics - January 2009 - Contents (Page H8) Drug Topics - January 2009 - Contents (Page 13) Drug Topics - January 2009 - Up Front (Page 14) Drug Topics - January 2009 - Up Front (Page 15) Drug Topics - January 2009 - Up Front (Page 16) Drug Topics - January 2009 - Up Front (Page 17) Drug Topics - January 2009 - Up Front in Depth (Page 18) Drug Topics - January 2009 - Up Front in Depth (Page 19) Drug Topics - January 2009 - Community Practice (Page 20) Drug Topics - January 2009 - Community Practice (Page 20a) Drug Topics - January 2009 - Community Practice (Page 20b) Drug Topics - January 2009 - Community Practice (Page 21) Drug Topics - January 2009 - Drug Pipeline: What to Watch in 2009 (Page 22) Drug Topics - January 2009 - Drug Pipeline: What to Watch in 2009 (Page 23) Drug Topics - January 2009 - Drug Pipeline: What to Watch in 2009 (Page 24) Drug Topics - January 2009 - Drug Pipeline: What to Watch in 2009 (Page 25) Drug Topics - January 2009 - Drug Pipeline: What to Watch in 2009 (Page 26) Drug Topics - January 2009 - Drug Pipeline: What to Watch in 2009 (Page 27) Drug Topics - January 2009 - OTC (Page 28) Drug Topics - January 2009 - OTC (Page 29) Drug Topics - January 2009 - OTC (Page 30) Drug Topics - January 2009 - OTC (Page 31) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 32) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 33) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 34) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 35) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 36) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 37) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 38) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 39) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 40) Drug Topics - January 2009 - Community-Aquired MRSA Infections (Page 41) Drug Topics - January 2009 - New Products (Page 42) Drug Topics - January 2009 - New Products (Page 43) Drug Topics - January 2009 - New Products (Page 44) Drug Topics - January 2009 - New Products (Page 45) Drug Topics - January 2009 - New Products (Page 46) Drug Topics - January 2009 - New Products (Page 47) Drug Topics - January 2009 - Viewpoint (Page 48) Drug Topics - January 2009 - Viewpoint (Page Cover3) Drug Topics - January 2009 - Viewpoint (Page Cover4)
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