Multiple IV lines pose risk to patients: 7 things to know

Researchers have examined the most common safety issues associated with infusions that use multiple intravenous lines, according to a report in Pharmacy Practice News.

Matthew Grissinger, RPh, the director of error reporting programs at the Institute for Safe Medication Practices presented the results of the study of more than 900 IV line errors reported from June 2004 to August 2013 to the Pennsylvania Patient Safety Authority at a recent meeting for the National Coalition for Infusion Therapy Safety.

Highlighted below are seven findings from the report and recommendations presented by Mr. Grissinger.

1. Infusion rate or line mix-ups (22.6 percent of errors), IV lines not attaching to patients (14.6 percent) and errors associated with piggyback infusions (12.8 percent) were the most common errors associated with multiple IV infusions. The errors tended to occur during setup.

2. The study found high-alert medications were involved in 71 percent of all multiple IV infusion errors and 92 percent of all IV line mix-ups.

3. Using the National Coordinating Council for Medication Error Reporting and Prevention, 48 percent of incidents were categorized as harm score D or greater, and 6.2 percent were categorized as harm score E or greater.

4. Nearly all (95 percent) of the errors reached the patient.

5. Heparin was the high-alert medication most frequently involved in errors (16 percent of errors), followed by insulin (7.6 percent) and parenteral nutrition (5.2 percent).

6. ICUs ranked highest among units where IV line errors were reported (30 percent), followed by medical-surgical units (14 percent) and telemetry units (6.6 percent).

7. To reduce the risks associated with multiple IV lines, Mr. Grissinger suggested:

  • Setting up infusions completely and one at a time
  • Administering high-alert medications as primary infusions
  • Restricting pump operation to qualified and credentialed personnel
  • Placing IV pumps and epidural pumps on opposite sides of patient beds to avoid mix-ups; and
  • Raising awareness of IV medication errors among facility staff.

Mr. Grissinger also suggested labeling patient IV lines in at least two locations to help match up lines.

 

 

More articles on patient safety and medical errors:
Physician groups pen letter to FDA urging transparency in biosimilar labeling
12 California hospitals penalized for patient safety issues
ECRI Institute: 10 patient safety concerns for healthcare organizations


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