Pediatric Informatics: Computer Applications in Child Health (Health ...

29 Understanding and Preventing Errors 379
29.7 Case Study: RCA, FMEA, and Error Proofing
in Continuous Infusions
Drug infusions are commonly used in Intensive Care Units to deliver sedative
and vasoactive medications. These infusions require that a mass of medication be
added to a volume of diluent and then infused at a rate that is then typically titrated
to effect. Voluntary reporting of near miss and adverse events revealed instances
where drug infusions were formulated incorrectly, infused at incorrect rates, or
prepared at concentrations that required either unmanageably low or excessively
high infusion rates. These experiences caused a multidisciplinary team to examine
and redesign the process used to prepare and infuse medications. The details of this
work have been published elsewhere. 8 Key elements of this project are described
here to illustrate the processes of RCA, FMEA, and error proofing.
The team evaluated errors experienced within our ICU as well as errors reported
in the literature. Two major error modes were identified: incorrect drug doses
delivered; and, inappropriate rates of fluid administration but correct drug doses.
Although the proximate contributor to incorrect dosing may often be a miscalculation,
there are multiple contributors that underlie this first error mode, many of
which are identified in List 29.3.
List 29.3 Contributors to incorrect dosing of drug infusions
Machines
� Existing IV pumps require titration in increments of 1 ml/h
� Computerized physician order entry incapable of necessary calculations
Materials
� Medication and diluent solutions come in preestablished mass/volumes –
requires recombination in correct proportions to arrive at correct infusion
solution
Methods
� No standard method in use – prescribers free to choose among several
(e.g. “rule of sixes”) or use their own approach
� All methods in use are cumbersome, requiring multiple calculations and
multiple independent variables
� Doses typically expressed in different units (e.g. mcg/kg/min) than infusions
(ml/h)
Measurements
� Medications commonly delivered already in solution – requires multiple
conversions to add correct mass of medication to correct volume of diluent
Mother-nature (environment)
� Bedside formulation subject to many environmental distractions that can
interrupt attention or workflow
People
� People have different abilities to calculate correctly without assistance
� People have been taught different methods
�
Often perceived to have insufficient staff for timely double-check