March 2020 DOI:10.33940/data/2020.3.3
Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports
​Author Biographies

 

Adam Krukas, MedStar Health National Center for Human Factors in Healthcare
Adam Krukas (Adam.J.Krukas@medstar.net) is a clinical informat-ics scientist for MedStar Health National Center for Human Factors in Healthcare (NCHFH) and a clinical pharmacist with MedStar Southern Maryland Hospital Center.

Ella S. Franklin, MedStar Health National Center for Human Factors in Healthcare
Ella S. Franklin is the nursing direc-tor at MedStar Health NCHFH.

Chris Bonk, MedStar Health National Center for Human Factors in Healthcare
Chris Bonk is a clinical human fac-tors specialist at MedStar Health NCHFH.

Jessica Howe, MedStar Health National Center for Human Factors in Healthcare
Jessica Howe is a senior human fac-tors research specialist and system safety specialist at MedStar Health NCHFH.

Ram Dixit, MedStar Health National Center for Human Factors in Healthcare
Ram Dixit is a human factors spe-cialist at MedStar Health NCHFH.

Katie Adams, MedStar Health National Center for Human Factors in Healthcare
Katie Adams is a research analyst at MedStar Health NCHFH.

Seth Krevat, MedStar Health National Center for Human Factors in Healthcare
Seth Krevat is assistant vice presi-dent for Safety at MedStar Health, a faculty associate at MedStar Health NCHFH, and an attending physician in Palliative Medicine at MedStar Georgetown University Hospital.

Rebecca Jones, Patient Safety Authority
Rebecca Jones is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis.

Raj Ratwani, Georgetown University School of Medicine
Raj Ratwani is the director of MedStar Health NCHFH, vice pres-ident of scientific affairs at MedStar Health Research Institute, and an associate professor at Georgetown University School of Medicine.

Abstract

Intravenous (IV) vancomycin is one of the most commonly used antibiotics in U.S. hospitals. There are several complexities associated with IV vancomycin use, including the need to have an accurate patient weight for dosing, to provide close monitoring to ensure appropriate drug levels, to monitor renal function, and to continue delivery of the medication at prescribed intervals. There are numerous healthcare system factors, including workflow processes, policies, health information technology, and clinical knowledge that impact the safe use of IV vancomycin. Past literature has identified several safety hazards associated with IV vancomycin use and there are some proposed solutions. Despite this literature, IV vancomycin–related safety issues persist. We analyzed patient safety event reports describing IV vancomycin–related issues in order to identify where in the medication process these issues were appearing, the type of medication error associated with each report, and general contributing factor themes. Our results demonstrate that recent safety reports are aligned with the issues already identified in the literature, suggesting that improvements discussed in the literature have not translated to clinical practice. Based on our analysis and current literature, we have developed a shareable infographic to improve clinician awareness of the complications and safety hazards associated with IV vancomycin and a self-assessment tool to support identification of opportunities to improve patient safety during IV vancomycin therapy. We also recommend development of clear guidelines to optimize health information technology systems to better support safe IV vancomycin use.

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