Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Jessurun, Janique Gabriëlle; Hunfeld, Nicole; Rosmalen, Joost van; Dijk, Monique van; Bemt, Patricia M. L. A. van den

doi:10.1007/s11096-021-01310-6

Cited by 5 publications

(4 citation statements)

References 56 publications

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“…One error type is incomplete mixing after a drug solution is added to the infusion fluid. Studies on the prevalence of this error type are scarce and have shown inconsistent results, with error rates varying from 0%-79% [ 1 – 3 ].…”

Section: Introductionmentioning

confidence: 99%

Evaluation of the importance of mixing during preparation of antibiotic infusions

Barzel

Jessurun

Bahmany

et al. 2022

BMC Pharmacol Toxicol

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Background The mixing step after medication addition to the infusion bag is frequently omitted during the preparation of drug infusions. However, the importance of mixing when preparing antibiotic infusions is still unknown. Methods The primary aim of this study was to assess the importance of the mixing step by comparing the concentrations of unmixed antibiotic infusions (cefuroxime, flucloxacillin, meropenem, and vancomycin) with the declared concentration at regular intervals during infusion. The secondary aim was to compare concentrations between preparation sites (hospital pharmacy versus clinical ward). Infusion bags were run through electronic infusion pumps. For cefuroxime, flucloxacillin, and meropenem, samples were collected 1, 15, and 20 min after starting the administration (infusion duration: 30 min). For vancomycin, samples were collected after 1, 60, and 110 min (infusion duration: 120 min). Vancomycin concentrations were measured using the Architect c4000 analyser and other concentrations using a validated UPC2-MS–MS multimethod. Results The median concentrations of the four antibiotics were comparable to the declared concentration at all three time points. No significant differences were found between preparation sites. Conclusions Spontaneous mixing occurred in the examined antibiotic solutions during normal handling.

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Section: Introductionmentioning

confidence: 99%

Evaluation of the importance of mixing during preparation of antibiotic infusions

Barzel

Jessurun

Bahmany

et al. 2022

BMC Pharmacol Toxicol

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“…Previous studies have indicated many potential causes of medication preparation and administration errors, such as lack of knowledge, high workload, distractions, and inadequately written communication, but studies on IAPEs in particular are scarce 31–35 . With regard to risk factors of IAPEs in clinical wards, a study at our institution showed that especially multistep preparations (versus single-step preparations), interruptions during preparation, weekend preparations (versus weekday preparations), time window 2:00 pm to 6:00 pm (versus 7:00 am to 10:00 am ), and preparation in adult wards (versus pediatric wards) were associated with an increased probability of IAPEs 36 . To examine the causes of the IAPEs and noncompliance to hygiene procedures, robust qualitative studies are needed.…”

Section: Discussionmentioning

confidence: 86%

“… 31 – 35 With regard to risk factors of IAPEs in clinical wards, a study at our institution showed that especially multistep preparations (versus single-step preparations), interruptions during preparation, weekend preparations (versus weekday preparations), time window 2:00 pm to 6:00 pm (versus 7:00 am to 10:00 am ), and preparation in adult wards (versus pediatric wards) were associated with an increased probability of IAPEs. 36 To examine the causes of the IAPEs and noncompliance to hygiene procedures, robust qualitative studies are needed.…”

Section: Discussionmentioning

confidence: 99%

Effect of a Pharmacy-based Centralized Intravenous Admixture Service on the Prevalence of Medication Errors: A Before-and-After Study

Jessurun¹,

Hunfeld²,

Rosmalen

et al. 2022

J Patient Saf

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ObjectivesIntravenous admixture preparation errors (IAPEs) may lead to patient harm. The primary aim of this study was to assess the effect of a pharmacy-based centralized intravenous admixture service (CIVAS) on IAPEs.MethodsWe conducted a before-and-after study in 3 clinical wards before CIVAS implementation and in the CIVAS unit 18 months after implementation. Intravenous admixture preparation error data were collected by disguised observation. The primary outcome was the proportion of admixtures with 1 or more IAPEs. Secondary outcomes were the type and potential severity of IAPEs, noncompliance to hygiene procedures, and nursing staff satisfaction with the CIVAS. The primary outcome was analyzed using a multivariable mixed-effects logistic regression model.ResultsOne or more IAPEs were identified in 14 of 543 admixtures (2.6%) in the CIVAS unit and in 148 of 282 admixtures (52.5%) in the clinical wards (odds ratio, 0.02; 95% confidence interval, 0.004–0.05). The most common IAPE types were wrong solvent or diluent (n = 95) and wrong volume of infusion fluid (n = 45). No potentially harmful IAPEs occurred in the CIVAS unit as opposed to 22 (7.8%) in the clinical wards. Disinfection procedures were better adhered to in the CIVAS unit. Overall nurse satisfaction with the CIVAS increased from a median of 70 (n = 166) 5 months after intervention to 77 (n = 115) 18 months after intervention (P < 0.001) on a 100-point scale.ConclusionsCentralized intravenous admixture service performed notably better than the clinical wards with regard to IAPEs and noncompliance to hygiene procedures. Nurses were satisfied with the CIVAS. Hence, the implementation of CIVAS is an important strategy to improve medication safety in hospitals.

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“…Jessurun и соавт. [18], выполненного методом скрытого наблюдения, ошибки при приготовлении смесей ЛП для инфузий были допущены медицинским персоналом в 367 из 614 случаев (59,8%) и состояли в неправильной технологии приготовления (n = 257) и в использовании неправильного объема раствора (n = 107).…”

Section: результаты и обсуждениеunclassified

Pharmaceutical Risks of Injection Therapy: The Role of a Nurse

Егорова

Abdullina

2023

Bezopasnost' i risk farmakoterapii

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Nurse-administered injections come with a special set of risks, including such pharmaceutical factors as preparation of medicinal products in a vial prior to administration, conditions of their further storage, labelling of packages, and the need for personalised dosing of solutions for injection.The aim of the study was to analyse Russian state standard GOST R 52623.4-2015 and identify factors contributing to the risk of nursing staff’s errors in preparing, storing, and labelling of medicinal products for injection.Materials and methods. The authors analysed GOST R 52623.4-2015 Technologies for Performing Simple Medical Services of Invasive Interventions and assessed the identified risks by the FMEA method (failure modes and effects analysis).Results. The authors identified pharmaceutical risks, causes, and sources of hazardous events that occur during administration of parenteral medicinal products. The standard does not instruct readers on the order of mixing medicines in a vial and on choosing solvents for lyophilised powders. There is no labelling procedure for opened vials in the document. It does not stress the inadmissibility of pre-administration storage of a syringe/dropper with a medicinal product. The document lacks information on the need to warm the aqueous solutions that are stored in a refrigerator and/or administered at a temperature of 36–38 °С as per the package leaflet. The standard does not include a procedure for visual estimation of the volume of a solution drawn into a syringe for individual dosing of medicinal products to children. According to the FMEA risk assessment, the highest risks are posed by the order of mixing medicines in a vial and by the storage of syringes/droppers prior to administration to patients.Conclusions. To improve the safety of injection therapy, it is necessary to supplement the state standard with the identified causes of hazardous events. Nursing staff in medical organisations would benefit from in-house training on prevention of pharmaceutical risks carried out with the help of specialists in pharmaceutics and from wider involvement in discussing pharmacotherapy errors.

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Prevalence and determinants of intravenous admixture preparation errors: A prospective observational study in a university hospital

Cited by 5 publications

References 56 publications

Evaluation of the importance of mixing during preparation of antibiotic infusions

Evaluation of the importance of mixing during preparation of antibiotic infusions

Effect of a Pharmacy-based Centralized Intravenous Admixture Service on the Prevalence of Medication Errors: A Before-and-After Study

Pharmaceutical Risks of Injection Therapy: The Role of a Nurse

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