Minimising IV infusion and drug hazards

Occasional errors of IV fluid and drug administration are inevitable. Their reporting is important, but theiroccurrence should never be made the pretext for disciplinary action unless there has been obvious negligence.Medical staff sometimes share responsibility for any administrative error that does occur by prescribing in an unclear or unnecessarily complex way. Staff new in place, at all levels, frequently find themselves work-ing under considerable pressure, and low staffing levels often impose further stress. Management sharesresponsibility for protecting staff from excessive pressure, for ensuring that unit policies are such as to minimise the risk of any error occurring, and (even more importantly) for seeing that the potential dangerassociated with any error is minimised by the use of ‘fail-safe’ routines like those outlined below. If seniorstaff over-react when mistakes occur errors may simply go unreported, increasing the risk of a recurrence.

It is, moreover, important to retain a sense of proportion in considering the issues raised by the rule that every error of drug prescribing has to be reported. While any error of commission is generally looked upon as a potentially serious disciplinary issue, serious errors of omission often go unremarked. Yet aninadvertent reduction in IV fluid administration due to tissue extravasation, failure to resite an infusion line promptly, or failure to set up the syringe pump correctly, is more likely to put a baby at hazard (fromreactive hypoglycaemia) than a transient period of excess fluid administration. Note that hypoglycaemia isparticularly likely to occur where a maintenance infusion of glucose saline IV is cut back or stopped abruptlyso that blood can be given (for guidance on this see the monograph on blood transfusion). Similarly, failureto give a dose of medicine may sometimes be just as hazardous as the administration of too big a dose.

Drug prescribing and drug administration call for close teamwork between the medical, midwifery and nursing staff. When an error does occur it is seldom one person’s sole fault, and this needs to beacknowledged if disciplinary action is called for. Where it is clear that a doctor and a midwife or nurse bothshare responsibility for any untoward incident, natural justice demands that any necessary disciplinaryaction is handled in an equable way.

Minor medication errors (i.e. any deviation from the doctor’s order as written on the patient’s hospitalchart) are extremely common. Rates of between one per patient day and two per patient week have beenreported in the United States. Prescribing errors are also common. Anonymous self-reporting schemes have been initiated in a few hospitals, as part of a more general risk management strategy, in an attempt to identify high-risk situations. Dilutional errors are particularly common in neonatal practice, and the individual drug guidelines in this compendium have been carefully framed so as to minimise these.

Ten golden rulesAttention to the following ten rules will help to minimise error and, even more importantly, ensure thatwhen an error does occur the impact is minimised:

1 Keep the prescribing of medication to a minimum, and use once or twice daily administration wherethis is possible.

2 Never have more than two IV infusion lines running at the same time unless this is absolutely necessary.3 Never put more than 30 ml of fluid at any one time into any syringe used to provide continuous IV fluid

or milk for a baby weighing less than 1 kg.4 Record the amount of fluid administered by every syringe pump by inspecting the movement of the

syringe and by inspecting the infusion site once every hour. Do not rely merely on any digital electronicdisplay.

5 In an analogous way, where the infusion of fluid from any large (0·5 l) reservoir is controlled by a peristaltic pump (or by a gravity-operated system with a gate valve and drop counter), it is always wiseto interpose a burette between the main reservoir and the control unit. Limiting the amount of fluid inthe burette limits the risk of accidental fluid overload, and recording the amount of fluid left in theburette every hour speeds the recognition of any administrative error.

6 Do not change the feeding or IV fluid regimen more than once, or at most twice, a day except for a verygood reason. Try to arrange that such changes as do have to be made are done during the morning orevening joint management rounds.

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Neonatal Formulary 6: Drug Use in Pregnancy and the First Year of Life, Edited by Edmund HeyC© 2011 by Blackwell Publishing Ltd. Published 2011 by Blackwell Publishing Ltd.

Minimising IV infusion and drug hazards

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7 Those few drugs that have to be administered over 30 minutes or more should be administered using a separate programmable syringe pump connected ‘pickaback’ onto an existing IV line. As an extra precaution, the syringe should never be set up containing more than twice as much of the drug as it isplanned to deliver. Do not adjust the rate at which the main IV infusion fluid is administered unlessthere is a serious risk of hyperglycaemia, or it is necessary to place an absolute restriction on the totaldaily fluid intake.

8 Do not routinely flush drugs or fluids through an established IV line except in the rare situations wherethis is specifically recommended in this compendium. To do so can expose the baby to a dangerouslyabrupt ‘bolus’ of drug. Using fluid from the main IV line to do this can also make the baby briefly andabruptly hyperglycaemic.

9 Beware giving a small newborn baby excess sodium unintentionally. The use of flush solutions of Hep-lok®, Hepsal® or 0·9% sodium chloride can expose a baby to an unintended excess of intravenoussodium. The steady infusion of 1 ml/hour of heparinised 0·9% sodium chloride (normal saline) to main-tain catheter patency is sometimes enough to double a very small baby’s total daily sodium intake. Socan intratracheal sodium chloride administration during tracheal ‘toilet’.

10 Treat the prescribing of potentially toxic or lethal drugs (such as chloramphenicol and digoxin, etc.)with special care. There are relatively few situations where it is really necessary to use such potentiallydangerous drugs.

If something does go wrongReport any significant error of omission or commission promptly so that appropriate action can be taken tominimise any possible hazard to the baby. Nine times out of ten, a senior member of staff with pharmaco-logical expertise will be able to determine that no harm has been done quite quickly and offer much neededreassurance to all concerned. If malfunction of a pump or drip regulator is suspected, switch the equipmentoff and replace it without touching the setting of the rate control switches, pass the equipment to medicalelectronics for checking without delay, and record the serial number of the offending piece of equipment onthe incident form.

Check and double check

1 Have you got the right drug? Check the strength of the formulation and the label on theampoule as well as the box.

2 Has it’s shelf life expired? Check the ‘use by ’ date.3 Has it been reconstituted and diluted properly? Check the advice given in the individual

drug monograph in this compendium.4 Have you got the right patient? Check the name band.5 Have you got the right dose? Have two people independently checked steps 1–4 with the

prescription chart?6 Have you picked up the right syringe? Deal with one patient at a time.7 Is the IV line patent? Have you got the right line? Is it correctly positioned? Could the line

have tissued?8 Is a separate flush solution needed? Have two people checked the content of the flush

syringe?9 Are all the ‘sharps’ disposed of? What about any glass ampoules?

10 Have you ‘signed up’ what you have done? Has it been countersigned?

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