Authors (including presenting author) :
Wong YL(1), Cheng KC(1), Wong SF(1), Chan TM(1), Tam YH(1), Yeung KW(1), Fung ML(1), Lau YS(1), Lee CH (1), Ng CP(1), Kwan YF(1)
Affiliation :
(1) Pamela Youde Nethersole Eastern Hospital, Intensive Care Unit
Introduction :
Intravenous (IV) infusion errors, particularly with high-risk medications, can significantly impact patient health. Root cause analyses have revealed that frontline staff often lack comprehensive knowledge of syringe pump operations. While technology allows for automation in changing modes to keep veins open, it can inadvertently introduce errors. Heavy workloads and the stress of emergency can result in inability to adhere to meticulous individual checking practices. Common pitfalls include assumptions, incorrect flow rates, missing decimal points, failure to trace the infusion line to ensure correctness and patency. There is an urgent need to develop a culture of vigilance about accuracy and safety of intravenous infusions.
Objectives :
To standardize the workflow of IV infusion checking and administration to ensure the safety and quality of care during intravenous infusions.
Methodology :
1. Video Demonstration: Produce an instructional video illustrating critical steps for infusion administration, particularly for high-alert medications, tips on correct use of infusion pumps, and verifying new medications. 2. Awareness Campaigns: Launch campaigns with slogans promoting proper checking and administration of medications, followed by silent observations to minimize Hawthorne effects and assess real-life compliance. Empower junior staff as observers to instill responsibility and act as role models to uphold medication safety. 3. Nursing Audit: Conduct regular audits on nursing practices related to IV infusions and provide rational recommendations. 4. Standardization: Develop standing order sets for both common and rarely prescribed medications to reduce prescription errors. 5. PDCA Modality: Implement the Plan-Do-Check-Act (PDCA) model to incorporate feedback and continuously improve processes.
Result & Outcome :
All nursing staff (100%) in the unit reviewed the video demonstrations, which clarified essential points for infusion administration. A slogan design competition empowered younger staff, promoting a culture of medication safety and consistent adherence to workflows. In view of 100% compliance rate in nursing audits, the program successfully raised awareness about infusion safety, praised good practices, and identified areas for improvement.
Conclusions
Meticulous checking prevents prescription and pump setting errors. The CQI program enhances safe practices and emphasizes regular competency assessments to maintain IV infusion safety. Moving forward, silent observations was planned to ensure the sustainability of standard practices.
