The average Walmart shopper understands risk reduction!

A few weeks ago, a pediatric nurse shared an intervention that lessened the likelihood of an IV medication error. Her story celebrated nursing advocacy, the ability of professionals on the front line to recognize risk, intervene proactively, and make things safer for patients.

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!

Risk points across the medication use system

Recently, Nurse Ausmed shared a great post about an intervention that lessened the likelihood of an IV medication error occuring in a pediatric patient. Her take-away lesson was "simplify, simplify," a core principle in safe medication practices.

Earlier this week, I wrote that Nurse Ausmed's online case study would lend itself to a basic excercise in identifying the latent (or upstream) conditions that often lead to error on the front line. Links to ideas about modeling human error (developed by James Reason) and some online pediatric medication safety resources were provided.

Here are my initial thoughts:

To answer the question, "Could the error-prone condition be identified and the potential for patient harm lessened before it reached the front line?" start by considering what the medication use system looks like:

The roles and responsibilities of professionals ("who does what, when, and how") may vary according to practice setting and applicable professional standards of care. Irrespective of setting, however, prescribing, transcribing, dispensing, administering, and monitoring are the units, or nodes, that make up the medication use system.

It's important to pause for a moment and take this in. As individuals, we typically focus on the portion of the system where our own professional duties lie, rather the system as a whole, making it difficult to see upstream opportunities.

Now consider the problem of errors in the medication use system:

Errors may originate at any point in the process. In the slide below, the red arrow illustrates how an error that began in the prescribing phase is not picked up, moving through all downstream defenses to reach the patient.

Seminal medication safety research shows the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient. This is why processes like independent double checks and automated clinical decision support are valuable: they make errors and error-prone conditions visible before they reach the patient.

Unfortunately, errors that originate in the administration phase are highly unlikely to be picked up before they reach the patient. This is why processes at the point of administration should be as simple, standard, accurate, and dependable as feasible. (I think of clinicians who administer medications and the processes they use as I would a flight crew: it's probably not a good idea to expect problems to be solved at 35,000 feet that could have reasonably been resolved on the ground or to use patchy processes to accomplish high-stakes, in-flight tasks.)

Later next week, I'll come back to this topic, using clinical information Nurse Ausmed shared to help identify strategies for preventing IV medication errors in peds that are on the high end of the risk reduction hierarchy. I'd hope you'll share the risk-reduction strategies you use when you care for pediatric patients.

Stay safe and come back soon! I've been thinking about something I heard Paula Poundstone say last week, and the next time you check in, you need to be ready to laugh!