Intravenous medication safety system averts high-risk medication errors and provides actionable data

Abstract

A major responsibility of nursing leaders is to implement systems and policies to improve patient and staff safety, avoid medication errors, and most importantly safeguard patients against harm. In the medication use process, the nurse at the bedside is the most vulnerable, and intravenous (i.v.) drug administration often results in the most serious medication error outcomes. At a 675-bed, tertiary-care "Magnet Hospital System," nurses played a key role in a multidisciplinary process that led to successful implementation of a computerized i.v. medication safety system. Software customization, staff training and product set-up were completed in approximately 2 months; 685 devices were installed in 3 hospitals within 12 hours. Nursing acceptance is excellent, and implementation of the system is thought to enhance nursing retention and recruitment. Preliminary data indicate an estimated 849 programming changes ("near misses") annually, ie, potential infusion errors averted by the i.v. medication safety system. A chronogram created from safety data demonstrates that most infusion error warnings occurred between 3:00 PM and 9:00 PM, with an unexpected peak at 6:00 PM. Implementation of the i.v. medication safety system has prevented potentially serious infusion errors and has provided previously unavailable, actionable continuous quality improvement data for best practice improvements.