Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting

Abstract

Objectives: Assess interventions’ impact on preventing IV infusion identification and disconnection mix-ups. Design: Experimental study with repeated measures design. Setting: High fidelity simulated adult ICU. Subjects: Forty critical care nurses. Interventions: Participants had to correctly identify infusions and disconnect an infusion in four different conditions: baseline (current practice); line labels/organizers; smart pump; and light-linking system. Measurements and Main Results: Participants identified infusions with significantly fewer errors when using line labels/organizers (0; 0%) than in the baseline (12; 7.7%) and smart pump conditions (10; 6.4%) ( p < 0.01). The light-linking system did not significantly affect identification errors (5; 3.2%) compared with the other conditions. Participants were significantly faster identifying infusions when using line labels/organizers (0:31) than in the baseline (1:20), smart pump (1:29), and light-linking (1:22) conditions ( p < 0.001). When disconnecting an infusion, there was no significant difference in errors between conditions, but participants were significantly slower when using the smart pump than all other conditions ( p < 0.001). Conclusions: The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency.

Labelling of intravenous drug delivery devices in critically ill patients: A scoping review

“…Labels with no colour standardization were observed in L1, 21 L2, 17 L3, 22 L6, 24 L11, 12 L15, 32 and L17 34 . Most of these documents referred to more failures in the recognition of the drugs used and the absence of information about the drugs on the labels, such as dilution, expiry date, and initials of the name of the person who prepared them.…”

“…Label colour‐coding was not used in seven documents. Among the labels with no colours, there was a balance between how information was inserted, whether handwritten (L1, 21 L3, 22 L6, 24 L17 34 ) or printed (L1, 21 L2, 17 L19 38 ). Handwritten information was more present than colour‐coded labels.…”

“…The identification of IV lines of drugs administered in critically ill patients is especially important in view of the visual disorganization resulting from many IV lines close to each other, mainly above and below the infuser pumps. 17,45 The interweaving of IV lines that exists when multiple infusions are administered to a single patient makes it difficult to discern one line from the other, in addition to screening to identify quickly and correctly what is being infused and its components. This increases the likelihood of medication administration errors, particularly line connections to incorrect devices, delivering inappropriate fluid to patients, and doses being incorrectly titrated or administered via ineffective routes.…”

“…This increases the likelihood of medication administration errors, particularly line connections to incorrect devices, delivering inappropriate fluid to patients, and doses being incorrectly titrated or administered via ineffective routes. 12,17 This problem was highlighted in the list of the top 10 dangers related to health technologies prepared by the Emergency Care Research Institute for the year 2015. 46 As a result of this issue, each infusion line should be labelled with the name of the drug, especially in the case of potentially dangerous drugs, which have a high risk of harming patients if errors occur.…”

“…13 Specifically regarding the step of identifying IV drugs, one study analysed the risks associated with the use of multiple medications in continuous infusion in a critical care setting, and found that 7.7% of nurses' errors consisted of the incorrect handling of IV lines during the infusion identification phase. 17 Another study that tested an intervention for anaesthesia safety affirmed that syringe changes and incorrect identification of anaesthetic drugs were common causes of errors, present in 40%-70% of incident reports. 18 Labelling standards for syringes, bags, and IV lines are strategies that strengthen the safety of institutional medication systems, that is, technologies that prevent the misidentification of IV drugs administered to critically ill patients.…”