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Project leaders :-  Harchintan   Devgan ,  Mouy  Ear,  Pabitra  Rai Sarita   Gurung  and  Sofie  Van  Hoeven

QUALITY IMPROVEMENT: Reducing medication errors associated with intravenous high risk medications running through the same IV infusion line

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Quality Improvement: Reducing medication errors associated with
intravenous high risk medications running through the Same IV
infusion line
MONASH University

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Medication errors can be defined as any preventable incident that gives rise to or may potentially compromise patients’ safety and the reduction in the likelihood for medications to be administered in a timely and effective manner (The US Food and Drug Administration (FDA) (2019). Medication error can be linked to various factors: - Professional knowledge and practices                                                                                        - Medication errors - Product labelling - Administrations - Monitoring and use. The key stakeholders: nurses, medical team, pharmacist, nursing management, information technology team, finance management team, hospital’s directors and executives and project team leaders.   Australian Safety and Quality Framework 1. Consumer Centred 1.7 Minimise risks at handover 1.9 If something goes wrong, openly inform and support the patient 2. Driven by Information 2.2 Collect and analyse safety and quality data to improve care 3. Organised for Safety 3.7 Design and operate facilities, equipment and work processes for safety 3.8 Take action to prevent or minimise harm from healthcare errors

Background
Medication With high-risk intravenous running
through the same intravenous infusion line have identified as a
concern within healthcare settings. A substantial amount Of literature in
regards to rnedication errors have suggested that some interventions can be
used to minimise patient harm linked to adverse effects to high-risk
medications and improve patient's health and safety (VVang et al., 2015). The
US Food and Drug Administration (FDA) (2019), have suggested that
medication errors can be defined as any preventable incident that gives rise
to or mav potentially compromise patients' safety and the reduction in the
likelihood for medications to administered in a timely and effective
manner. These events Can be linked to various factors including professional
practices, product labelling. administrations. monitoring and use.
Moreover, Studies have Suggested that intravenous administration Of
medications is more prone to produce errors due to the complexity Of the
process and steps involved to prepare and administer medication (Hani
al., 2019). Co-administration of intravenous medication is one Of the issues
that may arise running other medications through the same
intravenous infusion lines due to the incompatibility Of different
medications. Neininger et al. (2019) have conducted a study that indicates
incompati bility Of drug administration linked to intravenous infusions by 10%
Of the total analysed patients within a paediatric intensive care unit. Another
cross-sectional study in two intensive care units conducted by
Machotka et al. (2014) identified the 6.82% and 2.16% Of incompatible drug
infusions respectively.
The key stakeholders for the identified quality improvement project are
intensive care clinical staff including nurses. medical team. pharmacist,
nursing management and other teams including information technology
team, finance management team, hospital's directors and executives and
project team leaders.
This quality improvement project is aligned with each of the elements Of the
Australian Safety and Quality Framework- Firstly, it is consumer-centred as it
is aiming to minimise risks at handover where nurses are required to transfer
the information about high-risk intravenous medication Of the patients to
other nurses. Along with that, if something wrong. this project aims to
openly inform and support the patient as it is the responsibility of nurses if a
medication error occurs. Secondly, it is driven by information as it involves
collecting and analysing safety and quality data to improve care. In this
project, this element is achieved by involving a research team to collect and
analyse the data for presenting it to the intensive care staff each month.
Thirdly, it is organised for safety as it aims to design and facilities,
equipment and work processes for safety. In this project, we are going to use
red coloured labels on intravenous infusion lines to indicate the high-risk
medication. as well as warning passage in infusion pumps to alert while
administering the high—risk medications. In addition, the project aims to take
action for preventing or minimising harm from healthcare errors to improve
the health and safety Of the patients (Australian Commission on Safety and
Quality in Healthcare, 2010).

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To reduce the medication errors caused by high risk IV medications running through the same intravenous infusion line by 50% within 3 months in an intensive care unit in a public hospital.

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Potential idea: adding a warning window in the intravenous IV pumps  Quality improvement idea: labelling IV infusion lines which are administering high-risk medications with red.  A separate red label for date and time of the initiation of the infusion and when it was primed on the IV infusion line.  Data collection: VHIMS incident reports provides detailed analysis of the outcomes Desired outcomes: improved in patient safety and staff;  confidence for IV infusion medication administration and increased awareness of the

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running through the same line. Manufacturers should be for
the modificatjon of the waming window into infusion pumps in the
hospital settings. However, this quality improvement project involves
labelling IV infusion lines that are administering high-risk medications
in red. A separate red label can be placed on thc IV infusion line to
remind healthcare staff with the date and time of the initiation of the
infusion and when it was primed. After 3 days. the infusion line must
be changed to reduce the risk of infections or complications when
administering medications (Koyama et ale, 2020).
Only one medication should be prepared at a time before preparation
and labelling of a subsequent medicine. It is vitally important to gain
consent frorn clients prior to the administration of any IV medicatjons
or fluids (Beld et al-, 2018), Healthcare staff involved in dispensing,
prescribing, preparation and administration of medications wil be
required to attend an education session that will be run for 2 hours via
webinar which will be conducted by the quality improvement team
leaders. The education session will be commenced prior to the
implementation of the strategy and a pamphlet will be provided about
the importance of labelling and the introduction of the project. Once a
month, healthcare staff will be provided feedback on the effectiveness
of the strategy and will also statistics of incidents of
medication errors within the 3-month time frame. Healthcare staff are
provided an opportunity to complete a monthly survey to provide
feedback in regards to the implementation of the strategy. The
Victorian Health Incident Management System (VHIMS) is used to
collect data based on reports made in regards to medication-related
errors specific to the issue.
The Victorian Agency for Health information (VAHI) (2020) releases
statewide reports on VHIMS incidents which also include detailed
analysis of the outcomes.

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Resources he National Safety and Quality Health Service(NSQHS) standard 4th indicates medication safety  Action 4.11 :  Identification of high-risk medications in the organization. Action 4.01  Identifies  integrating clinical governance Action 4.07  Identifying of adverse drug reactions. Team member: Quality improvement leaders, nurses, doctors, pharmacist, information technology team, budget management team, hospital directors and project team members. Resources needed for the QI project: Traffic light  colour  label, IV infusion pump. Leadership style Transformational leadership style

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PLAN   Quality improvement goal and planning the project  DO  Implementation and collection of data STUDY   Analysing and comparing the data ACT  Adopting and adapting the quality improvement project

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Labelling IV line in red colour according to traffic light system for high risk medications as well as having healthcare professionals to check the IV line  Providing webinar educational session before and after the project will increase staff's awareness regarding high-risk medications administration  This project will further develop health and safety of the patients who are our priority

Main Results
By labelling the IV infusion lines in red colour which indicated high risk
medications according to the traffic light system and also encouraging
the healthcare professionals to physically check the labels of the IV
infusion lines as part of the medication safety check and documenting
about it as mandatory line assessment would result in reduction in
medication errors while administering high-risk medications. By
providing webinar educational sessions before initiating and after
completing the project would also benefit in a sense of comfort by
helping ICIJ nursing staff to be familiarise and aware when
administering high-risk medications. The educational webinars will
enhance healthcare professionals' knowledge and awareness among
the ICIJ clinical staff regarding high-risk medications. The educational
session would further develop the healthcare professionals' education
about high-risk medications like dosage, contraindications and side
effects. Most importantly, this project will help in increasing the health
and safety of the patients who are our priority while providing care for
our patients.

Figure. 1 Estimated result from the quality improvement project in barchart

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Australian Commission on Safety and Quality in Healthcare. (2010). Australian Safety and Quality Framework for Health Care. Retrieved 22 September 2021, from   https://www.safetyandquality.gov.au/sites/default/files/migrated/Australian-SandQ-Framework1.pdf . Beld , K.H.M.L.,  Alting , E.K., Taxis, K. (2018). A systematic literature review on strategies to avoid look-alike errors of labels.  European Journal of Clinical Pharmacology, 74 , 985-993.   https://doi.org/10.1007/s00228-018-2471-z   Choi, S., Goh, C., Adam, M., & Tan, O. (2016). Transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment.  Human Resources For Health ,  14 (1).   https://doi.org/10.1186/s12960-016-0171-2 Hani, C.,  Vonbach , P.,  Fonzo-Christe , C.,  Russmann , S.,  Cannizzaro , V., &  Niedrig , D. F. (2019). Evaluation of Incompatible  Coadministration  of Continuous Intravenous Infusions in a  Pediatric /Neonatal Intensive Care Unit.  The journal of  pediatric  pharmacology and therapeutics ,  24 (6), 479-488.   https://doi.org/10.5863/1551-6776-24.6.479 Hospicode . ( n.d. ). Table Top [Photograph].   https://hospicode.com/product/table-top/   Koyama, A.K., Maddox, C.S.S., Li, L.,  Bucknall , T., & Westbrook, J.I. (2020). Effectiveness of double checking to reduce medication administration errors: a systematic review.  BMJ Quality & Safety, 29 (7), 595-603.  http://10.1136/bmjqs-2019-009552     Machotka , O.,  Manak , J.,  Kubena , A., &  Vicek , J. (2015). Incidence of intravenous drug incompatibilities in intensive care units.  Biomedical Papers, 159 (4), 652-656.   http://dx.doi.org/10.5507/bp.2014.057   Med one group. (2018). Manual Versus Electric Pump IV: How to Save a Life. Retrieved 25 September 2021, from   https://www.medonegroup.com/aboutus/blog/manual-versus-electric-pump-iv .

National Safety and Quality Health Service Standards. (2014).  Medication Safety Standard . Retrieved 23 September 2021, from   https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard Neiniger, M. P., Buchholz, P., Frontini, R., Kiess, W., Siekmeyer, W., Bertsche, A., Siekmeyer, M., & Bertsche, T. (2019). Incompatible intravenous drug combinations and respective physician and nurse knowledge: a study in routine paediatric intensive care. European journal of hospital pharmacy,  26 (4), 214-217.   http://dx.doi.org/10.1136/ejhpharm-2017-001248   Smith, M. (2015). Are you a transformational leader?.  Nursing Management ,  42 (9), 44-50.   https://doi.org/10.1097/01.numa.0000403279.04379.6a   The Joint Commission. (2021). Sentinel event alert 63: optimising smart infusion pump safety with DERS.  Journal on Quality and Patient Safety, 47 (6), 394-397.   http://doi.org/10.1016/j.jcjq.2021.03.013     U.S. Food and Drug Administration. (2019). Working to Reduce Medication Errors. Retrieved 22 September 2021, from   https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors .   Victorian Agency for Health. (2020). Medication incidents the focus in new VHIMS report.   https://www.bettersafercare.vic.gov.au/about-us/news/medication-incidents-the-focus-in-new-vhims-report      Wang, H.F.,  Jin, J.F., Feng, X.Q., Huang, X., Zhu, L.L., Zhao, X.Y., & Zhou, Q. (2015). Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to joint commission international accreditation and in the post-accreditation era. Therapeutics and Clinical Risk Management, 11, 393-406.   Https://doi/10.2147/TCRM.S79238 Wittich, C., Burkle, C. M., & Lanier, W. L. (2014). Medication Errors: An Overview for Clinicians.  Mayo Clinic Proceedings, 89 (8), 1116-1125.   https://doi.org/10.1016/j.mayocp.2014.05.007

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 Australian Commission on Safety and Quality in Healthcare. (2010). Australian Safety and Quality Framework for Health Care. Retrieved 22 September 2021, from   https://www.safetyandquality.gov.au/sites/default/files/migrated/Australian-SandQ-Framework1.pdf . Beld , K.H.M.L.,  Alting , E.K., Taxis, K. (2018). A systematic literature review on strategies to avoid look-alike errors of labels.  European Journal of Clinical Pharmacology, 74 , 985-993.   https://doi.org/10.1007/s00228-018-2471-z   Choi, S., Goh, C., Adam, M., & Tan, O. (2016). Transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment.  Human Resources For Health ,  14 (1).   https://doi.org/10.1186/s12960-016-0171-2 Hani, C.,  Vonbach , P.,  Fonzo-Christe , C.,  Russmann , S.,  Cannizzaro , V., &  Niedrig , D. F. (2019). Evaluation of Incompatible  Coadministration  of Continuous Intravenous Infusions in a  Pediatric /Neonatal Intensive Care Unit.  The journal of  pediatric  pharmacology and therapeutics ,  24 (6), 479-488.   https://doi.org/10.5863/1551-6776-24.6.479 Hospicode . ( n.d. ). Table Top [Photograph].   https://hospicode.com/product/table-top/   Koyama, A.K., Maddox, C.S.S., Li, L.,  Bucknall , T., & Westbrook, J.I. (2020). Effectiveness of double checking to reduce medication administration errors: a systematic review.  BMJ Quality & Safety, 29 (7), 595-603.  http://10.1136/bmjqs-2019-009552     Machotka , O.,  Manak , J.,  Kubena , A., &  Vicek , J. (2015). Incidence of intravenous drug incompatibilities in intensive care units.  Biomedical Papers, 159 (4), 652-656.   http://dx.doi.org/10.5507/bp.2014.057   Med one group. (2018). Manual Versus Electric Pump IV: How to Save a Life. Retrieved 25 September 2021, from   https://www.medonegroup.com/aboutus/blog/manual-versus-electric-pump-iv .

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  National Safety and Quality Health Service Standards. (2014).  Medication Safety Standard . Retrieved 23 September 2021, from   https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard Neiniger, M. P., Buchholz, P., Frontini, R., Kiess, W., Siekmeyer, W., Bertsche, A., Siekmeyer, M., & Bertsche, T. (2019). Incompatible intravenous drug combinations and respective physician and nurse knowledge: a study in routine paediatric intensive care. European journal of hospital pharmacy,  26 (4), 214-217.   http://dx.doi.org/10.1136/ejhpharm-2017-001248   Smith, M. (2015). Are you a transformational leader?.  Nursing Management ,  42 (9), 44-50.   https://doi.org/10.1097/01.numa.0000403279.04379.6a   The Joint Commission. (2021). Sentinel event alert 63: optimising smart infusion pump safety with DERS.  Journal on Quality and Patient Safety, 47 (6), 394-397.   http://doi.org/10.1016/j.jcjq.2021.03.013     U.S. Food and Drug Administration. (2019). Working to Reduce Medication Errors. Retrieved 22 September 2021, from   https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors .   Victorian Agency for Health. (2020). Medication incidents the focus in new VHIMS report.   https://www.bettersafercare.vic.gov.au/about-us/news/medication-incidents-the-focus-in-new-vhims-report      Wang, H.F.,  Jin, J.F., Feng, X.Q., Huang, X., Zhu, L.L., Zhao, X.Y., & Zhou, Q. (2015). Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to joint commission international accreditation and in the post-accreditation era. Therapeutics and Clinical Risk Management, 11, 393-406.   Https://doi/10.2147/TCRM.S79238 Wittich, C., Burkle, C. M., & Lanier, W. L. (2014). Medication Errors: An Overview for Clinicians.  Mayo Clinic Proceedings, 89 (8), 1116-1125.   https://doi.org/10.1016/j.mayocp.2014.05.007

QUALITY IMPROVEMENT: Reducing medication errors associated with intravenous high risk medications running through the same IV infusion line

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