This is a 121Kb file containing Presentation (pdf) file and recording of the actual webinar, which was originally aired on May 3, 2013
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Anthony (Tony) Easty PhD, P.Eng, CCE, Team Leader, HumanEra; Senior Scientist, University Health Network
Sonia Pinkney, MHSc, P.Eng, Human Factors Engineer, HumanEra, University Health Network
Mark Fan, MHSc, Human Factors Analyst, HumanEra, University Health Network
The administration of multiple intravenous (IV) infusions to a single patient is common in critical care environments and the likelihood of adverse drug events increases by 3% with each additional IV medication. However, until recently, minimal systematic research had been conducted to identify specific factors that can increase the risk of infusion error in a multi-infusion environment and validate risk mitigation strategies.
A mixed-methods approach was used to identify patient safety risks associated with administering and managing multiple IV infusions and strategies to mitigate those risks. These methods included:
- Literature and incident database review
- Technology scan
- Observational field studies
- Interviews with academic nursing educators
- Province wide survey
- Experimental data from a simulated intensive care unit
The findings were organized using the following themes: secondary (piggyback) infusions, IV line identification, IV line setup, dead volume and IV bolus administration. The results confirmed that errors occur and factors contributing to these errors are present in the province. However, based on the results from the simulation study, there are clinical, technological and training based interventions that improve safety.
This presentation will focus on the following:
- Error rates for tasks in all issue themes based on experimental evidence.
- The effectiveness of 13 interventions (e.g., video-based training, IV labels and IV tubing organizers) in reducing errors.
- Common areas of variability in clinical practice that may benefit from standardization or greater awareness.
- Recommendations, validated by a multidisciplinary expert panel, to improve patient safety.