ASHP InterSections ASHP InterSections

June 1, 2008

Getting to the Root of IV Medication Errors

            In November 2007, an intravenous medication error that could have been fatal for the newborn twin daughters of actor Dennis Quaid and his wife Kimberly occurred. Sadly, this event is only the latest in a series of recent errors that injured or killed a child. Part of the tragedy of these events is that we, as healthcare providers, continue to ignore the lessons that should have been learned.

            Even though several of these errors occurred with medications that have now been re-labeled, the contributory factors remain. Non-standardization; poorly designed, incomplete, or ambiguous labeling; unsafe storage practices; and inadequately trained or supervised personnel—all are part of a IV medication-use system that must be overhauled.

            The biomedical literature is replete with research on the causes of IV medication errors and successful preventive strategies, some of which have been used effectively. But this knowledge has not made a lasting, sustainable change in the way hospitals and health systems work; in packaging, labeling, and equipment design improvements; or in the creation of new mandatory regulatory or quality standards.

            So, ASHP is stepping into the gap to bring about fundamental, lasting change. Together with the ASHP Research and Education Foundation, we are calling together key players July 14–15 to an IV Safety Summit to study this issue in depth and seek new solutions.

            Panelists include nationally renowned experts like medication-safety advocate David Bates, M.D., with Brigham and Women’s Hospital; Carolyn Clancy, M.D., with the Agency for Healthcare Research and Quality; and Gerald J. Dal Pan, M.D., director of the Office of Drug Safety for the FDA. Other participants include representatives from healthcare professional associations, industry, federal agencies, safety and quality oversight groups, and human factors experts.

            Together, we will examine current evidence on the causes of intravenous errors, such as clinical issues, human factors, process design, and technology, as well as effective error-prevention methods. Our goal is action that will create sustainable changes in our hospitals and health systems. It’s time to put an end to IV medication errors, once and for all.

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