Cheshire and Merseyside Critical Care
Published Date: 19th July 2016
Publication Authors: Barton G
Background
The intravenous route is the most common route of drug administration on critical care units. Intravenous drug administration can be particularly hazardous on critical care due to complex drug regimes, multiple concurrent infusions and the unstable nature of patients. In response to 800 incidents, the National Patient Safety Agency (NPSA) issued guidance on the safer use of injectable medicines, this specifically recommended regular audit in this area. A recent multinational study of parenteral administration in critical care units found a prevalence of parenteral administration errors of 74.5 events per 100 patient days. Only 19% of the 113 units involved reported no parenteral administration errors in the 24 hour study period. 12 of 1328 patients enrolled in the audit experienced permanent harm or death as a direct result of an administration error highlighting that intravenous administration is a patient safety issue on critical care units.The NPSA has also released an alert about arterial line infusions. Only sodium chloride 0.9% should be infused via arterial lines and this must be prescribed and checked. The Wirral University Teaching Hospitals Medicines Management Policy (MMP) and other Trust's policies require all parenteral medicines to be prescribed and the drug to be labelled. The label must include the drug, dose, volume, diluent, patient's name, date and time of preparation, expiry and the names of the people preparing and checking the infusion. Drug administration must comply with a legally valid prescription/authorisation and be signed for on the prescription chart.
Objectives
To measure compliance with prescribing of arterial line infusions against NPSA recommendations.To assess accuracy of intravenous drug administration against the written instructions on the prescription, as required by MMPTo assess labelling of intravenous drug infusions against the MMP standards.To determine whether administration of intravenous drugs is documented on the prescription chart in accordance with MMP requirements.
Method
The CMCCN pharmacist group decided to conduct the audit as a 'snapshot', and capture data only for drugs being administered at the time of the audit. A prospective audit would have been impractical and may have altered the outcome. A data collection form was designed and piloted in each unit. Modifications were made to reduce ambiguity. The aim was to collect data for 10 patients per site over a period of 4 weeks in May/June 2009. Thepharmacist or nurse completed the data collection form recording general patient data, the total number of intravenous drugs prescribed and the total running at the time of the audit. For each intravenous drug or arterial line infusion being administered, more detailed information was recorded: completeness of label, details of compatibility of reconstitution fluid and Y-site compatibility (if applicable), safety of administration including use of volumetric pump, documentation on the prescription chart and checking against prescription.
Results
Seven critical care units took part in the audit and 71 patients were included. Seven hundred intravenous drugs or arterial line infusions were prescribed for these patients and data were collected for 345 running at the time the audit was conducted. 70% (30/43) of arterial line infusions running at the time of audit were not prescribed. 13% (44/345) of drugs running were not prescribed, this included three noradrenaline infusions that were prescribed but were running at a higher rate than the range authorised. Of the drugs not prescribed 68% (30/44) were arterial line infusions. 100% of all drugs being infused at the time of audit were given via an appropriate pump, diluted in a compatible fluid and administered via a central line if required. There was one incident of precipitation in the line; all other infusions running together were compatible. 69% of drug labels did not contain all of the required information. The majority of labelling errors related to expiry with 56% not recorded or incorrect, followed by 21% missing route and 23% missing second check signature. The dose of the drug was missing in 3% of labels and patient name was missing in 2%. 87% of drugs were documented on the prescription chart (26% were double signed).
Discussion
Local education is needed for prescribers regarding the requirement to prescribe all parenterals including arterial line infusions and therefore comply with the Medicines Act 1968 and NPSA arterial line alert.3 Drug labelling and drug chart documentation requirements need to be reinforced with nursing staff. Consideration should be given to double signing prescription charts; a second check is required by the NPSA arterial line alert and documentation of this check is essential to prove that it has occurred. As a result of this audit practice has changed at one hospital which previously did not document continuous infusions on the drug chart. Another hospital has implemented a system for signing on shift changes that all infusions are running correctly and according to the prescription andthere is an increased awareness of the requirement to prescribe arterial line infusions. The CMCCN group aim to re audit later this year. There are several limitations of this audit: the prescription that we audited against was frequently incomplete, some data collection forms were incomplete and the data collection form was also subject to ambiguity. The 'snapshot' nature of the audit meant intermittent infusions and boluses were likely to be missed, timing of data collection varied between units, the contents of the infusions bags could not be confirmed as preparation was not witnessed and not all Trusts in the region were able to participate in the audit.
Hughes, D; Barton, G; Gibson, L. (2010). Audit of intravenous drug administration and arterial line Infusions in Cheshire and Merseyside Critical Care Network (CMCCN). Clinical Pharmacist. 2 (9 (supplement)), S33
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