The Agency for Healthcare Research and Quality (U.S. Department of Health and Human Services) has reported that “Medical errors are responsible for injury in as many as 1 out of every 25 hospital patients; an estimated 48,000-98,000 patients die from medical errors each year.  Errors in healthcare have been estimated to cost more than $5 million per year in a large teaching hospital, and preventable health-care related cost the economy $17-$29 billion per year.”

 

The errors may result in a patient receiving the wrong medication, a test result being misread or even a misdiagnosis.  A study by the Agency for Healthcare Research and Quality found that preventable adverse drug events caused 1 out of 5 injuries or death per year in the hospitals studied.

 

The source of a significant number of the adverse drug events is the hospital pharmacy IV room.  These are among some of the most difficult to detect and are extremely dangerous to the patient.

 

Dennis Tribble, Chairman of the American Society of Health-Systems Pharmacists, Section on Pharmacy Informatics and Technology, is urging the hospital pharmacy community to examine and employ some of the advancements in technology to improve patient safety. 

 

Tribble commented, “IV doses are generally mixtures of clear liquids—once mixed, visual inspection of doses simply cannot uncover errors.  Human diligence is simply insufficient.  In the course of their daily work, hospital pharmacists inspect hundreds, sometimes thousands, of IV preparations—the vast majority of which are correctly prepared.  Finding the rare errors amongst hundreds of correct doses stresses human capability.”

 

An additional modification of container labeling has been employed in some hospitals but this still relies on human diligence.  Other new patient safety technologies such as Bar Code Medication Administration and Computerized Physician Order Entry do not impact the IV room.

 

What Can Help?

• Adding in process checks
• Redesign barcode systems to help identify “wrong drugs”Automate in-process verifications
• Final testing that formulated IV solution is correct

Early studies have shown the Aria technology can be used successfully for this application. Aria testing can be used both in-process and for final IV formulations.  A simple, inexpensive test which requires little technical expertise to perform provides a simple straightforward indication of whether or not the IV solution has been prepared correctly and is ready for use.