Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Prevention of i.v. drug mistakes
- Frank Overpelt (28 March 2003)
-
Re: Prevention of i.v. drug mistakes
- Christopher M Byatt (28 March 2003)
-
The checking philosophy of nurses
- Phillip J. Colquitt (29 March 2003)
-
Where's the ethnography?
- Brenda A Roche, Amy Scammell, Edward Parkes, Carolin Hagelskamp (4 April 2003)
-
Medication errors detected in infusions
- Christopher Anton, Nigel J Langford, and Robin E Ferner (9 April 2003)
-
Self-checking needed.
- Phillip J. Colquitt (10 April 2003)
-
Proposal of a one-step formula for continuous infusion of medication
- Manuel Cidras (19 April 2003)
-
Re: The checking philosophy of nurses
- Steven J Rogers (18 June 2003)
-
Air in the line
- Phillip J. Colquitt (20 June 2003)
|
|
|||
|
Frank Overpelt, ICU-nurse / teacher of nursing Leiden University Hospital 2333 ZA Leiden, the Netherlands
Send response to journal:
|
Thank you for this article. I've been a nurse for 22 years and have made and seen a number of i.v. drug mistakes. One of the things that helps prevention of mistakes is the standard check and double check protocols that are in place in most of the hospitals in the Netherlands. There are a few other measures that can help prevent mistakes. One of these is the introduction of an information system like the one we have on the intanetsite of Leiden University Hospital. In this information system all drugs that can be administered by injection are mentioned plus the medication it can, or does not, interact with. Also it states the time for infusion, and the maximum dose/ml. If this is not enough, the nurse who administers the medication can opt for the use of the perfusor, yes the very same that is being used for the continuous administration of medication. Its primary function is to administer fluids, with or without medication, over a period of time. I know that on the non-ICU wards they are not available everywhere, but in the ICU, and especially the pediatric ICU they are "abundant", and a big help in preventing temporary or terminal overdose. It takes a little more time but makes and keeps you more aware of the risks. For all nurses who do not know the effect of (temporary) overdose, go to the ICU and see what happens when you administer a drug too fast to an instable patient who is being monitored for ABP/HR and SP02. You will note that it takes more time to stabilize the patient than it takes to hook up a perfusor. The results of the study will help me in my other job: the teaching of nursing; most of my work involves the learning of skills in a Skillslab setting. I've been warning students about the effect of medication mistakes, especially too rapid infusion i.v. medication. I strongly believe that making people/students aware of the risks is part prevention. Thanks, Frank Overpelt. Competing interests: None declared |
|||
|
|
|||
|
Christopher M Byatt, Consultant geriatrician Hereford County Hospital, Union Walk, Hereford HR1 2ER
Send response to journal:
|
This study confirms what most of us informally are aware of - when people are under pressure performance suffers. Whatever one knows or can do (i.e. one's competence) is not always translated into day to day activity (performance). Who else has not taken a short cut today in one or more clinical or administrative activities, because they had five other important, or urgent (or both!), things to get done before the end of the day? There would appear to be two logical potential solutions: a) Use infusors rather than require nurses to spend time administering i.v. medication b) Staff the wards sufficiently to allow nurses to have the time to devote to this function, in addition to the multifarious other tasks accruing in their portfolios. The latter option would allow time for the nurses actually to have human contact with the patient for a limited but relatively undisturbed period of time (as when specialist oncology nurses administer cytotoxic drugs). Given the extra cost this would represent to a resource limited system, I think I can predict which option would be the more attractive to someone designing a service with cost control as a (the?) significant driver. Competing interests: The amount of work I would like to finish to a satisfactory standard, and the amount of time I am prepared to devote to my working life |
|||
|
|
|||
|
Phillip J. Colquitt, RN Independent Comment
Send response to journal:
|
Hardly surprising that nurses, fragmented into being all things to all people who can see them, and unwise enough to take on such a "role", would find themselves deskilled. And probably as damaged professionally as the patients are clinically. If a task(eg. IV therapy) is important enough that it threatens life when said task is done badly, then the person doing that task, must be doing only that task. Sadly, many nurses subscribe to the boastful claim that they can do ten things at once, in a sort of female chauvinist inspired way that appeals to some university lecturers. Checking everything with another nurse, is a failed philosophy, and not cost effective. The recent case reported where a nurse placed an intracranial nasogastric tube, after another nurse verified the gastric position[1], reminds one of the false sense of security found in numbers. If taken to it’s logical extreme, this checking philosophy would find nurses unable to drive, unless they had another nurse in the car, to make sure that the green light really was a green light. Because if it’s not a green light, life could be at stake! Many nurses are techno-phobic, and won’t use the IMED intra-venous infusion device’s secondary rate function to deliver a bolus. The machine does it so much better. Phillip J. Colquitt New Farm, Queensland, Australia. 1. Metheny NA. Inadvertent intracranial nasogastric tube placement. Am J Nurs. 2002 Aug;102(8):25-7. No abstract available. PMID: 12394035 [PubMed - indexed for MEDLINE] Competing interests: Machinery |
|||
|
|
|||
|
Brenda A Roche, Researcher Battersea Research Group, Bolingbroke Hospital, Wakehurst Road, London. SW11 6HN., Amy Scammell, Edward Parkes, Carolin Hagelskamp
Send response to journal:
|
As researchers who specialise in qualitative methodologies we read with great interest the recent study by Katja Taxis and Nick Barber (BMJ, 326, pp684-687). Whilst we appreciate the attempts of the authors to shed some light on the nature of intravenous drug errors, and an often neglected area of clinical practice, we were left somewhat perplexed as to the authors’ understanding of ‘ethnography’. Whilst we are aware that the use of qualitative methods in medical related research is relatively new, we are concerned, as are others, about the quality of research that is being published in this area. As published, this study is not an ethnographic study and is barely qualitative. The authors have conducted an observational study, one it seems with roots in quantitative not qualitative methodology. This is most obvious from the outcome measures used where the authors set out to document the ‘number, type and clinical importance of errors’. One clue to reviewers would be the use of terms like ‘number’. Also later we find that the researchers have used ‘a validated scale to assess the clinical importance of intravenous drug errors’. Ethnographic studies do not rely on the use of quantitative scale assessments. The use of ‘confidence intervals’ to analyse supposedly ‘ethnographic data’ is again somewhat worrying. Lack of time here precludes us from expansion, but we refer interested parties to the following sources for an exploration of the meaning of ‘ethnography’ and ethnographic methods: Agar, M. 1980 The Professional Stranger: An Informal Introduction to Ethnography. Spradley, J.P. 1979 The Ethnographic Interview. Hammersley, M. and Atkinson P. 1995 Ethnography: Principles and Practices. In a broader sense, this paper raises concerns for us about the understanding of qualitative methods in medicine. The misrepresentation of this study as ‘ethnography’ can unfortunately do nothing but undermine the work of qualitative researchers. Ethnographers and other qualitative researchers are constantly called upon to defend the integrity and rigour of their methodologies against quantitative ones and we feel it our duty to defend proper qualitative research against methodological drift. There already exists an abundance of misunderstanding about qualitative research without prestigious journals like the BMJ contributing to the situation. Competing interests: None declared |
|||
|
|
|||
|
Christopher Anton, Administrative Co-ordinator West Midlands Centre for Adverse Drug Reaction Reporting, Nigel J Langford, and Robin E Ferner
Send response to journal:
|
As Taxis and Barber report, (1) there are few prospective studies into the incidence of errors in intravenous administration of drugs. There are problems in devising such studies because the very act of being observed may alter behaviour and introduce bias the Hawthorn effect; and because some errors inevitably escape detection. Observational studies such as those of Taxis and Barber can therefore underestimate the incidence of medication errors. We and our colleagues in three other centres assessed errors in the administration of acetylcysteine used to treat paracetamol poisoning by measuring the concentration of drug in the infusate. (2) The regimen is complex, and each patient receives three infusion bags, each of a different volume, and containing a dose of acetylcysteine adjusted by patient weight. (3) We had expected that most of the bags would contain within 10% of the intended dose, but this was true in only 66 of 184 bags (36%); and in 17 bags (9%) the actual concentration differed from that which was intended by more than 50%. Taxis and Barber suggest that centralised preparation in the pharmacy department might reduce infusion errors. Pharmacists prepared infusions in one of our centres (centre C). Results were similar to those in two of the other three centres, suggesting that there are difficulties even when pharmacists are responsible (see Figure). Potentially serious dosing errors will persist until better systems are devised for the whole process of prescribing, making up, and giving medicines.
References 1. Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. British Medical Journal 2003; 326: 684-7. 2. Ferner RE, Langford NJ, Anton C, Hutchings A, Bateman DN, Routledge PA. Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. British Journal of Clinical Pharmacology 2001; 52: 573-7. 3. British Medical Association, Royal Pharmaceutical Society of Great Britain. British National Formulary 44. Wallingford: Pharmaceutical Press, 2002: 24. Competing interests: None declared |
|||
|
|
|||
|
Phillip J. Colquitt, RN Independent Comment
Send response to journal:
|
Editor, Can there be a “system” of drug administration independent of cultural considerations? I read the study cited[1] in the response by Anton et al., and though it’s not mentioned in the response, I wasn’t surprised to find the authors of the cited study noting the higher rates of arithmetic error in drug calculations and drug mixing among their study participants in clinical settings, compared to industrial arithmetic error rates with “self- checking”. Administrators should endorse attitudes which allow nurses to do their work without the excess and paranoia of checking each others every move and utterance. Studying nurses who are already busy studying each other, is madness. Educating nurses to “tertiary” standard, only to systematically deskill them in an out of date hospital culture of cloistered “sisterhood” which seems preoccupied with bedpan rinsing, and call bell answering, and baby-feeding, is counterproductive. Phillip J. Colquitt, New Farm, Qld., Australia PS. Please feel free to comment on errors. [1] Ferner RE, Langford NJ, Anton C, Hutchings A, Bateman DN, Routledge PA. Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. British Journal of Clinical Pharmacology 2001; 52: 573-7. Competing interests: Education |
|||
|
|
|||
|
Manuel Cidras, Neonatologist Neonatal Unit. Materno-Infanitl Hospital. 35016 Las Palmas de G.C. Spain
Send response to journal:
|
The recent study by Taxis and Barber (1) reports that two out of three potentially severe errors were preparation errors of continuous infusion drugs. Dosage of continuous infused medications can be complicated and time-consuming. Standard solutions, equations (2,3) and even graphics (4) are published to make easier calculations. But, not one works in a universal way. A formula, ready to use in all ages and any clinical status, is: D/RxVxW/QxCxK where D is dose in mg/kg/h or IU/kg/h, R is rate in ml/h, V is volume of solution in ml, W is patient’s weight in kg, Q is the quantity of drug in the container in mg or IU, C is volume of container (ampoule or bottle) in ml, and K is a constant with two possible values: 1 in case of dose given in mg/kg/h or IU/kg/h, and 0.06 in case of dose given in mcg/kg/min to convert it to mg/kg/h (60 min divided by 1000 mcg). The result is the amount of fluid to take out of container to prepare the patient’s solution. A equation with seven variables is difficult to remember, but can be easier to hold in mind with all consonants less "y" of two words: "DRiVeWay QuiCK". Perhaps this one-step equation lessens the errors using continuous infusion medications. 1. Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ 2003;326:684-7. 2. Chernow B (Ed). The pharmacologic approach to the critical ill patient. Third Edition. Baltimore, Williams & Wilkins. 1994. 3. Young TE, Mangum B (Eds): Neofax: A manual of drugs used in neonatal care. Fourteenth Edition. Raleigh, Acorn Publishing, 2001. 4. Lamiell JM, Wallis JG. Computer-generated drug-dosing nomograms. Crit Care Med 1988; 16:1246-7. Competing interests: None declared |
|||
|
|
|||
|
Steven J Rogers, Staff Nurse/Clinical Skills Trainer Addenbrooke's Hospital, CB2 2QQ
Send response to journal:
|
On the subject of bolus doses from IMED infusion devices, if Phillip is referring to the Gemini models then the secondary infusion rate is not a bolus dose system at all and such confusion can lead to further problems. The use of the secondary infusion rate assumes both a separate fluid container and giving set attached to the primary administration set. In the absence of a second giving set the fluid will be taken from the primary container reducing the volume available to be infused without decrementing the volume to be infused display. Multiple bolus doses can significantly reduce the actual volume without reducing the amount the pump will attempt to infuse so that the container can empty (apparently) prematurely leading to problems such as air in the line and discontinuity of infusion while a new fluid container and giving set are prepared. Such delays with critical infusions were identified in the original article as potentially serious. Of the volumetric infusion pumps in use at this hospital none are able to deliver a true bolus though several have secondary infusion rates that are used as such by staff. I have no information about how many errors have occurred as a result of this but I feel that only if there were an extreme deterioration of the patient’s condition would anything be reported. Competing interests: Trying to teach too many pumps to too many nurses |
|||
|
|
|||
|
Phillip J. Colquitt, RN Independent Comment
Send response to journal:
|
Ed, Gemini PC-1 IMED electronic infusion devices are getting some specific attention - they need it - despite their undoubted efficiency and elegance compared to the older manual IV fluid administration technique. Regarding potential problems identified by trainer Steve[1], where a bolus injection given using the secondary rate function of the IMED, is not part of the total volume displayed. The problem barely exists, and is virtually negated in view of the controlled rate provided by metered bolus infusion, as against uncontrolled bolus given manually[2]. IMEDs and other such devices rarely display exact correlation between visible contents of IV bag and total volume given via the display panel, and most nurses make minor program adjustments of the volume to be given, to prevent air in the line. Serious consequences directly related to IV lines being temporarily unprimed is hypothetical. Manufacturers of IMEDs could easily design out the air in line effect that occurs when an infusion “runs through”. Until then, evacuation of air in line remains a necessary nursing skill for hands on nurses. Phil Colquitt RN [1] Steven J RogersRe: The checking philosophy of nurses. BMJ Rapid Responses.(18 June 2003) [2] Taxis K. Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ 2003; 326: 684 Competing interests: Worry |
|||
