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Evaluation of interventions to reduce infusion errors at The Alfred Hospital
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmaceutical Biosciences.
2014 (English)Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
Abstract [en]

Introduction: Medical errors are estimated to be the 8th largest cause of death in the USA and medication-related errors the largest single cause of errors in hospital. Intravenous administration is strongly associated with higher risk and more severe errors than other medication routes and the rates of intravenous drug errors are high. Multiple interventions have been made at the Alfred Hospital during the last five years in order to reduce infusion errors and improve safety intravenous therapies.

Aim: Evaluation of the impact of infusion related medication safety initiatives on infusion errors at The Alfred Hospital 2009-2014.

Materials and Methods: Prospective observational studies at a tertiary referral teaching hospital. The study included data collection in 2014 and analysis of data collected in 2009, 2011, 2012 and 2014 in order to make comparison. Discrepancies and errors found were evaluated for risk severity by an expert panel.

Results: The number of significant errors identified were 63 of 469 infusions assessed (13.4%) 2009, 54 of 744 (7.3%) 2011, 23 of 685 (3.4%) 2012 and 37 of 701 (5.3%) 2014. The number of potentially serious errors were estimated to 1 (0.2%) 2009, 2 (0.3%) 2011 and none 2012 and 2014. Compliance to the drug library was 90.4% in 2014 when looking at all infusion and 39.1% when looking at the infusions with significant errors. A pharmacist had annotated the drug chart 67.2% of all infusions 2014 and 45.9% when looking at the infusions with significant errors.

Conclusions: Intravenous infusion errors have significantly decreased since infusion interventions have been made at the Alfred. Smart pumps intercept serious errors and pharmacy annotation, as well as drug library compliance, lower risks of significant errors. Education on the use of smart pumps and non-compliance should be prioritized in order to further decrease infusion related errors.

Abstract [sv]

Bakgrund till studien: Läkemedel som administreras via blodet, så kallad intravenös administration, medför större risk och är starkare associerad med allvarliga misstag än läkemedel som administreras via t.ex. mun och ändtarm. På the Alfred Hospital har man under de senaste fem åren utfört flera åtgärder för att minska misstag associerade med intravenös administration för att på så vis förbättra den intravenösa säkerheten. Dessa åtgärder inkluderade att låta en farmaceut granska patienters läkemedelsjournaler, införa en ny generation av intravenösa pumpar, så kallade smartpumpar, samt uppdatera och förnya smartpumparnas läkemedelsbibliotek.

Syftet med studien: Utvärdering av de säkerhetsåtgärder som gjorts för att minska infusionsrelaterade misstag på the Alfred Hospital 2009-2015.

Hur studien utfördes: Studien utfördes på the Alfred Hospital, ett sjukhus i Melbourne Australien, och inkluderade insamlande av data från 2014 samt analyserande av tidigare insamlad data från 2009,2011, 2012 och 2014. Potentiella avvikelser och misstag funna utvärderades utifrån risk- och allvarlighetsgrad av en gemensam expertpanel.

Resultat och slutsats: Misstag associerade med intravenös administration har kraftigt minskat sedan man på the Alfred Hospital utfört diverse säkerhetsåtgärder. Nya intravenösa pumpar, så kallade smartpumpar, minskar risken för att allvarliga intravenösa misstag inträffar. Intravenösa misstag minskar även då man låter en klinisk farmaceut granska läkemedelsjournalen samt då man använder smartpumparnas inbyggda läkemedelsbibliotek. För att man i framtiden ska minska infusionsrelaterade misstag ytterligare bör utbildning om riskerna med att inte använda smartpumpar prioriteras.

Place, publisher, year, edition, pages
2014. , 34 p.
Keyword [en]
Infusion errors, IV errors, Smart pumps, pharmacy annotation
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-242062OAI: oai:DiVA.org:uu-242062DiVA: diva2:782181
External cooperation
The Alfred Hospital, Melbourne
Subject / course
Educational program
Master of Science Programme in Pharmacy
Available from: 2015-01-20 Created: 2015-01-20 Last updated: 2015-01-20Bibliographically approved

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