After a hospital received several event reports of wrong and expired intravenous (IV) fluids caught before reaching patients, the medication safety officer investigated how these products were supplied. This institution purchases all their plain IV fluids from one manufacturer, so the products appear very similar. The fluids were stocked in clean utilities rooms throughout the patient care units in blue storage bins with white labels describing the contents by product number. Although nursing uses barcode medication administration (BCMA) technology prior to administering drugs to patients, the hospital lacked any technology to help ensure storeroom staff placed the correct product in its bin.
This information was shared with the patient safety director and the reporting nurse, who appreciated a significant look-alike risk. Their group developed a plan to provide visual differentiation of each product, evaluate fluids and quantities stocked, and reorganize the fluids according to prevalence of use.
Since they could not change the appearance of the products in stock, the group worked to color code storage according to the type of solution. Their original plan was to purchase different color bins; however, the cost was prohibitive, so instead they purchased different color labels which clearly state the type of fluid and bag size. These labels were used on storage bins throughout the patient care units and storeroom. A small supply of different color bins was purchased for the storeroom staff to use when transporting the fluids to the floor to prevent intermingling.
To better understand the supply maintained on each unit, the medication safety officer met with nurse managers to review items stocked compared to actual use. Each unit reevaluated its supply to ensure more appropriate quantities of regularly used items were available. This reduced the number of different fluid products from 22 to 15. Of the 15 products kept, nine had periodic automatic replacement (PAR) levels adjusted to match average use. This helped reduce risk of products expiring and waste.
When the new labels were implemented, the group reorganized the fluids to store them more ergonomically for staff. Prior to this, irrigation solutions and combination fluid products were stored at eye level and high use items, like sodium chloride 0.9% or lactated Ringer’s 1-liter bags, were stored on the bottom shelf. Staff routinely needed to bend down to take or restock these products. Solutions also were organized by product number, which separated different bag sizes of the same fluids. In the new system, the same fluids are grouped together and more routinely used items are placed higher on shelves.
