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Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes

At a 644-bed, tertiary-care, “magnet” system, intravenous (IV) infusion medication errors were determined to present the greatest risk of harm. An IV infusion safety initiative focused on multidisciplinary collaboration, standardization of IV dosing, and medication safety technology. A modular IV infusion safety system was determined to provide the greatest “speed to impact” in reducing harm. In 9 months, the system averted 166 overdoses; IV Medication Harm Index analysis identified 33 as highest risk overdoses (heparin and propofol accounted for 73 percent of these highest risk averted overdoses). Although 78 percent of infusion devices were used with critical care patient types, 52 percent of the highest risk-averted overdoses occurred with noncritical care types. For patient controlled analgesia, respiratory monitoring modules helped avert numerous undesired outcomes. Other results included improved best practices, communication, nursing satisfaction, retention, and recruitment. From January to June 2006, infusion safety systems recorded 328 averted high-risk overdoses. Based on the Agency for Healthcare Research and Quality’s (AHRQ) value of $6,000 per accidental drug overdose, the system helped avert 6-month costs of $1,968,000. IV infusion safety systems provide rapid, effective, and cost-effective patient safety improvement.