At a recent meeting of the AAMI Healthcare Technology Safety Institute, researchers from the University of Toronto released a report that provides nine specific recommendations to reduce the risks associated with multiple intravenous infusions.
Multiple IV infusions are prone to a variety of errors, including mix-ups of infusion lines, bags and pumps. Such errors can lead to medication errors and serious patient harm. UT researchers conducted fieldwork and experimental research to determine the risks of multiple IV infusions and established nine recommendations to improve safety in specific areas, including secondary infusions, line identification, line set-up and removal and IV bolus administration.
The nine recommendations are as follows:
1. At the beginning of a secondary infusion, ensure that the primary infusion is inactive (no drip visible) and the secondary is active (drip visible).
2. A continuous infusion that carries the risk of significant patient harm must be administered as a primary infusion — never a secondary infusion.
3. To prevent tubing mix-up, attach all secondary infusions to primary infusion sets with a back-check valve.
4. Gowns with snaps, ties or Velcro on the shoulders and sleeves should be used.
5. For emergency medication infusions, label associated primary tubing as the emergency medication line at the injection port closest to the patient.
6. Multiple IV infusions should be set up one at a time and as completely as possible (this includes mechanical set-up and pump operation).
7. Use multiport or multi-lead connectors rather than multiple three-way stopcocks to join multiple IV infusions in a single line.
8. A bolus should only be administered via the primary continuous infusion pump if the dose parameters are programmed by the clinician into the pump, without changing the primary infusion parameters. Avoid manually increasing the infusion rate to administer a bolus of a primary continuous infusion.
9. Hard upper limits should be set by hospitals for as many high-alert medications as possible to prevent the administration of a bolus by manually increasing the primary flow rate.
Multiple IV infusions are prone to a variety of errors, including mix-ups of infusion lines, bags and pumps. Such errors can lead to medication errors and serious patient harm. UT researchers conducted fieldwork and experimental research to determine the risks of multiple IV infusions and established nine recommendations to improve safety in specific areas, including secondary infusions, line identification, line set-up and removal and IV bolus administration.
The nine recommendations are as follows:
1. At the beginning of a secondary infusion, ensure that the primary infusion is inactive (no drip visible) and the secondary is active (drip visible).
2. A continuous infusion that carries the risk of significant patient harm must be administered as a primary infusion — never a secondary infusion.
3. To prevent tubing mix-up, attach all secondary infusions to primary infusion sets with a back-check valve.
4. Gowns with snaps, ties or Velcro on the shoulders and sleeves should be used.
5. For emergency medication infusions, label associated primary tubing as the emergency medication line at the injection port closest to the patient.
6. Multiple IV infusions should be set up one at a time and as completely as possible (this includes mechanical set-up and pump operation).
7. Use multiport or multi-lead connectors rather than multiple three-way stopcocks to join multiple IV infusions in a single line.
8. A bolus should only be administered via the primary continuous infusion pump if the dose parameters are programmed by the clinician into the pump, without changing the primary infusion parameters. Avoid manually increasing the infusion rate to administer a bolus of a primary continuous infusion.
9. Hard upper limits should be set by hospitals for as many high-alert medications as possible to prevent the administration of a bolus by manually increasing the primary flow rate.
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