Aligning the lines: an analysis of IV line errors
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Wollitz, Amanda, author Grissinger, Matthew, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, [2014]
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Infusions, Intravenous Medication Errors Patient safety Risk Management Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- From July 2004 through August 2013, Pennsylvania healthcare facilities reported to the Pennsylvania Patient Safety Authority 907 events of intravenous (IV) line errors. Reports were analyzed and assigned an error category based on event description. The most common errors occurred during setup and included rate of infusion mix-up or line mix-up (22.6%, n = 205), IV lines not attached to patients (14.6%, n = 132), and errors associated with piggyback infusions (12.8%, n = 116). High-alert medications were involved in 71.0% (n = 644) of all errors, with heparin being the most frequent medication reported (16.6%, n = 151). Nearly half of the reports (48.1%, n = 436) were categorized as harm score D or greater (as defined by the National Coordinating Council for Medication Error Reporting and Prevention), which indicates they reached the patient and required some type of intervention. While it is difficult to determine the exact causes of reported events, more than half of the submitted events involved the setup of IV lines. Risk reduction strategies focused on setting up infusions completely and one at a time, administering high-alert medications as primary infusions, utilizing infusion sets with back-check valves, labeling lines, limiting pump setup to qualified and credentialed personnel, placing IV pumps and epidural pumps on opposite sides of the patient's bed, and raising awareness of the risk of IV errors.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (8 pages)).
- NLM Unique ID:
- 101630036 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101630036