Last week, I went back to this pediatric infusion case, reviewing what a system analysis of the medication use process and seminal medication safety research tell us about risk. The take-away lesson? Errors that originate upstream are more likely to be discovered and corrected before the error reaches a patient while errors that originate close to the point of administration are less likely to be detected.
Here's another image prepared using the same seminal medication error data, illustrating more take-away lessons: errors that originate downstream are not only more likely to reach a patient, they are more likely to cause harm when they do.
Source: Leape L; Bates D; Cullen D; Cooper J; Demonaco H; Gallivan T; et al.Systems analysis of adverse drug events. ADE Prevention Study Group JAMA. 1995;274(1):35-43.
Now, let's look at the details provided in the original post:
- the patient was 3 years old
- the care setting was one that routinely cared for pediatric patients
- the patient was receiving an IV medication
- the medication infusing was not commonly used
- the professional staff were not using a drug administration protocol familiar to them
- no written guidelines for how to prepare the infusion or administer this particular drug were available
- the medication infusion required titration (the dosing unit provided in the post: mg/kg/hr)
On-duty personnel at the end of the night shift were observed struggling to perform the calculations needed to titrate the prescribed dose (0.84 mg/kg/hr) while adjusting doses in mL/hr increments. Calculations of this nature are possible, but they are complex, error-prone, and more likely to be botched when performed by fatigued workers. It's also high-stakes work that's occurring while the infusion is attached to the patient, about as far downstream as you can go in the medication use process.
A routine medication, dose, and rate check performed by the oncoming nursing team revealed that the medication was being administered as prescribed. A change in the medication concentration advocated by the oncoming nurse simplified the rate and dose relationship, removing the need to perform complex mathematical calculation to titrate the dose at the bedside. Risk was reduced.
This represents very good work by the team at the bedside, who used tools available to them to reduce error potential. Other positive call-outs include: the setting was one that routinely cared for pediatrics; independent double-checks are part of the clinical culture; staffing was such that a seasoned nurse had time to consider risk-reduction strategies and advocate for change; and the professional culture is described as one that values inter-disciplinary communication and respect.
When I first read this case, though, I was struck by the image of front line clinicians trying to avert disaster, much the same as an airline crew in flight might have to work to solve an emergent in-flight problem. Where was the ground crew, I wondered? How much of the time-robbing, disaster-avoidance described by the nurse at the bedside could have been averted by better "pre-flight" processes? Do solutions implemented by bedside clinicians, using a relatively closed set of variables, yield the strongest possible risk reduction, or does the process become just a little "less risky"?
Administering intravenous medications to a pediatric patient is a high-stakes activity, but it is not a rare one, at least in this setting. (Spoiler alert: You're not going to find a link to a mega-document with a full-blown Failure Modes and Effects Analysis about pediatric medication infusions!)
Instead, let me leave you with a few high-level risk reduction strategies to consider, many that you'll recognize if you practice in a setting where The Joint Commission (TJC) standards frame clinical care. I'm not claiming expertise in TJC standards interpretation nor am I offering advice about what any particular organization should do to minimize risks associated with pediatric medication administration. (You can, however, find some here.)
But I like to think that anything that can be understood by the average Walmart shopper is worth sharing, so I'm closing with a few observations about how this Walmart shopper sees risk-reduction.
Risk-reducing activities are often reflected in TJC standards, and the "science behind the compliance" is often based on failure mode and effects analysis. These are things the "ground crew" should be thinking about to ensure the people on the flight deck have what they need to get the job done:
- Establish standard concentrations for all IV medications (even the ones not often used). When IV medications are added to an organization’s formulary, they are subject to specific processes (usually under the auspices of a Pharmacy & Therapeutics Committee). These should ensure that standard drug concentrations are defined and incorporated into the tools used by professionals to prescribe, dispense, and administer the medication.
- IV drug infusions are ideally prepared in a pharmacy. When operational barriers to pharmacy preparation occur--in care settings without 24 hour pharmacy or in regions where unit-based drug preparation is the standard of care--staff members who admix medication should have access to guidelines specifying the standard concentration along with detailed admixing instructions. Clinicians who administer infusions should have easy-access to sanctioned dose conversion charts.
- “Smart” infusion pumps, with drug libraries programmed to reflect standard concentrations, make weight-based dosing even more simple. Dose-checking programming modes remove the need for manual calculations while immediately alerting clinicians--just prior to administration, the last possible discovery point--if an inappropriate dose has been inadvertently programmed.
There are other high-end strategies for reducing pediatric drug errors, some in development and some already being used in clinical settings. I encourage you to share yours. As for me, it's Friday, and I'm off to Walmart!