As part of a facility’s efforts to become a high reliability organization (which maintains high levels of safety, quality, and efficiency) to achieve zero patient harm, they turned their attention to addressing reports of medication errors related to preparing intravenous (IV) products. The standard practice at the root of the problem was that the preparer pulled back the syringe after completing the preparation to indicate the volume added, with no way to assure that the volume added agrees with the amount indicated in the pulled back syringe and that the correct amounts of each drug have been used during compounding.
They redesigned the pharmacy process, replacing the unreliable “pull back” method with an IV workflow system. The new process uses barcode scanning of ingredients to prevent errors prior to preparation and photographs of the individual ingredients and corresponding syringes that are used in the process to verify accuracy of the ingredients. Photographic documentation of the preparation process also assures the correct volume has been added, and IV products are scanned at the point of delivery to track individual products throughout preparation and delivery. The facility saw a statistically significant decrease in the number of reported preparation errors after implementing the new process, and all these reported errors involved situations in which the technology was bypassed.
