iLearning Recorded Webinar
Intravenous Adverse Drug Events:
Improving Patient and Clinician Safety
Overview
Adverse drug events and reactions pose a serious threat to patients and clinicians with the IV route greatly increasing these risks. Before clinicians can improve patient safety, a thorough understanding of the types and causes of the risk associated with all intravenous (IV) administration is needed. The patient, the IV fluids and medications, multiple IV administration systems on a single patient and different infusion methods play a role in adding to this challenge of safe IV infusion. The presentation will allow the clinician to explore the methods to mitigate these risks.
This learner-paced education activity is intended primarily for RNs with a responsibility for or an interest in ensuring safety in patients with multiple intravenous lines.
Upon completion of this presentation, participants will be able to:
1) Based on definitions of ADE and ADR, differentiate adverse drug events and adverse drug reactions.
2) Analyze risk associated with IV administration set management and medication administration
3) Evaluate methods to mitigate the risk of multiple IV infusion sets and medication administration
Participants will complete the recorded webinar learning activity. They will view the presentation, then register to complete the evaluation and take the post-test on the website. They will submit the documentation as directed. A bibliographic reference is included for those wishing additional information.
Upon successful completion of the entire online program and submission of required documentation, participants will be granted 1 contact hour. No partial credit will be granted.
Provider approved by the California Board of Registered Nursing, Provider Number 08747, the District of Columbia Board of Nursing, Provider Number 50-574, the Florida Board of Registered Nursing, Provider Number 50-574 and the Georgia Board of Nursing, Provider Number 50-574.
1. Successful completion: Participants will read the printed module, then register online, achieve a score of 80% on the post-test and submit required documentation. An active printer connection is required to print the certificate of completion.
2. Conflict of interest: Planners disclose no conflict of interest. The subject matter experts disclose salary or honorarium from the commercial support entity; they have signed a statement agreeing to present material fairly and without bias.
3. Commercial company support: Fees are underwritten by education funding provided by MedLiteID.
4. Non-commercial company support: None.
5. Alternative/Complementary therapy: None.
6. Educational Dimensions supports efforts to eliminate health care disparities and implicit bias in medical treatment along lines of race, ethnicity, gender identity, sexual orientation, age, socioeconomic status, other characteristics through CNE activities addressing direct patient care.
Participants successfully completing the activity and submitting required documentation will be permitted to print a certificate of completion. Participants are advised to retain the certificate for eight years following activity completion.
Replacement of misplaced certificate is available from Educational Dimensions. There is a fee for this service. Request a replacement by contacting us.
Guide to Study
The following steps will assist you in your successful completion of this eLearning Activity.
1. Read the content or view the recorded presentation. If you want contact hours at the completion of studying the eLearning material, you will be required to register, complete an evaluation and take a post-test prior to printing your Certificate of Completion. We urge you to complete the eLearning activity once you have started. However, if you do need to come back later, you can sign in with your email and eLearning ID.
2. First Time Visitors will be asked to register using an email address as your User Name. Make a note which email address you have used. Then you will create an eLearning ID using a combination of at least 6-10 letters or numbers. Please make a note of your eLearning ID and if for some reason you forget, you may request that your eLearning ID be sent to you. The web site is secured by Trustwave.
3. Return Visitors: If you have registered already you do not need to register again. Just Sign In using your email and eLearning ID.
4. Evaluation Form: Once you have registered or signed in you will be asked to complete an evaluation form and submit it. This is required to obtain the Certificate of Completion.
5. Post-test: A post-test, based on the content of the eLearning activity, will need to be taken. A passing score of 80% is required. This is required to obtain the Certificate of Completion.
6. Printing Your Certificate of Completion: Once you have successfully passed the post-test you will be able to print your Certificate of Completion. You will be given an opportunity to verify the information that will be printed on your certificate. Please make sure your printer is ready to print. You will not have access to the certificate page on later visits unless you contact us. Once you choose to print the Certificate of Completion, it will not be possible to make corrections. To obtain a corrected certificate you will need to contact Educational Dimensions. Fees may apply.
7. Browser recommendations: We require using an up-to-date browser with JavaScript enabled. You must enable cookies from this site in order to access the secure areas.
8. If you encounter any technical problems during this eLearning activity, please contact us.
Recorded Webinar Video
CNE Certificate Process
Note: Your computer should be connected to a printer before completing the Post-Testing in order to permit printing your course certificate.
IV Adverse Drug Events: Improving Patient and Clinician Safety
Reference list
AAMI. Improving the safe use of multiple IV infusions. AAMI Foundation. www.aami.org. Published 2016. Accessed 2019.
Benlabed M, Perez M, Gaudy R, et al. Clinical implications of intravenous drug incompatibilities in critically ill patients. Anaesthesia Critical Care & Pain Medicine. 2019;38(2):173-180.
Bernatchez SFP, Schommer KRNBSNVABC. Infection prevention practices and the use of medical tapes. AJIC: American Journal of Infection Control. 2021;49(9):1177-1182.
Blandford A, Furniss D, Lyons I, et al. Exploring the Current Landscape of Intravenous Infusion Practices and Errors (ECLIPSE): protocol for a mixed-methods observational study. BMJ open. 2016;6(3):e009777.
COHEN MR. ISMP medication error report analysis. Hospital pharmacy. 2003;38(4).
Doesburg F, Oelen R, Renes MH, Bult W, Touw DJ, Nijsten MW. Towards more efficient use of intravenous lumens in multi-infusion settings: development and evaluation of a multiplex infusion scheduling algorithm. BMC Medical Informatics and Decision Making. 2020;20(1). doi:10.1186/s12911-020-01231-w.
Duprey MS, Al-Qadheeb NS, O’Donnell N, et al. Serious Cardiovascular Adverse Events Reported with Intravenous Sedatives: A Retrospective Analysis of the MedWatch Adverse Event Reporting System. Drugs - Real World Outcomes. 2019;6(3):141-149.
Estock JL, Murray AW, Mizah MT, Mangione MP, Goode Jr JS, Eibling DE. Label design affects medication safety in an operating room crisis: a controlled simulation study. Journal of patient safety. 2018;14(2):101.
Giuliano KK, Blake JWC, Butterfield R. Secondary Medication Administration and IV Smart Pump Setup. The American journal of nursing. 2021;121(8):46-50.
Gorski LA, Hadaway L, Hagle ME, et al. Infusion Therapy Standards of Practice, 8th Edition. Journal of Infusion Nursing. 2021;44(1S):S1-S224.
ISMP. FDA and ISMP lists of look-alike drug names with recommended tall man letters. 2016.
ISMP. ISMP List of High-Alert Medications in Acute Care Settings. Institute for Safe Medication Practices. https://www.ismp.org/recommendations/high-alert-medications-acute-list. Published 2018. Accessed 7/25/2022, 2022.
ISMP. Safe practice guidelines for adult IV push medications. In. Horsham, PA: Institute for Safe Medication Practices; 2015.
Kane-Gill SL, Kirisci L, Verrico MM, Rothschild JM. Analysis of risk factors for adverse drug events in critically ill patients. Critical care medicine. 2012;40(3):823.
Kovach JV, Revere L, Black K. Error proofing healthcare: an analysis of low cost, easy to implement and effective solutions. Leadership in Health Services. 2013;26(2):107-117.
Krukas A, Franklin ES, Bonk C, et al. Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports. Patient Safety. 2020;2(1):17-17.
Kuitunen S, Niittynen I, Airaksinen M, Holmström A-R. Systemic causes of in-hospital intravenous medication errors: a systematic review. Journal of patient safety. 2021;17(8):e1660.
Maison Ol, Tardy Ca, Cabelguenne D, et al. Drug incompatibilities in intravenous therapy: evaluation and proposition of preventive tools in intensive care and hematology units. European Journal of Clinical Pharmacology. 2019;75(2):179-187.
Marwitz KK, Giuliano KK, Su W-T, Degnan D, Zink RJ, DeLaurentis P. High-alert medication administration and intravenous smart pumps: A descriptive analysis of clinical practice. Research in Social and Administrative Pharmacy. 2019.
McDowell SE, Mt-Isa S, Ashby D, Ferner R. Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. BMJ Quality & Safety. 2010;19(4):341-345.
Messing EG, Abraham RS, Quinn NJ, Duthie EA. CE: Using Smart IV Infusion Pumps Outside of Patient Rooms. The American journal of nursing. 2022;122(2):36-43.
Morrison TL, Laney C, Foglesong J, Brennaman L. Color-coded labels cued nurses to adhere to central line connector change. Clinical Nurse Specialist. 2016;30(2):106-109.
Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2016;124(1):25-34.
NCCMERP. Contemporary View of Medication-Related Harm, A New Paradigm. National Coordinating Council for Medication Error Reporting and Prevention. https://www.nccmerp.org/sites/default/files/nccmerp_fact_sheet_2015-02-v91.pdf. Published 2015. Accessed 7/20/2022, 2022.
NCCMERP. Recommendations for Improving Medication Safety by Reducing Inappropriate Polypharmacy. National Coordinating Council for Medication Error Reporting and Prevention. https://www.nccmerp.org/recommendations-improving-medication-safety-reducing-inappropriate-polypharmacy. Published 2021. Accessed 7-25-2022, 2022.
Nuckols TK, Paddock SM, Bower AG, et al. Costs of Intravenous Adverse Drug Events in Academic and Nonacademic Intensive Care Units. Medical Care. 2008;46(1):17-24.
PA Advisory PPS. Tubing misconnections: making the connection to patient safety. Pa Patient Saf Advis. 2010;7(2):41-45.
Pinkney S, Fan M, Chan K, et al. Multiple intravenous infusions phase 2b: Laboratory study. Ontario health technology assessment series. 2014;14(5):1.
Prabhakar A, Malapero RJ, Gabriel RA, et al. Medication errors in anesthesia. The Journal of medical practice management : MPM. 2015;30(6 Spec No):41-43.
PSNet. Medication errors and adverse drug events. In: Agency for Healthcare Research and Quality. https://psnet. ahrq. gov/primers …; 2019.
Schnock KO, Dykes PC, Albert J, et al. The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. BMJ Quality & Safety. 2017;26(2):131. doi:10.1136/bmjqs-2015-004465.
Simmons D, Symes L, Guenter P, Graves K. Tubing Misconnections Normalization of Deviance. Nutrition in Clinical Practice. 2011;26(3):286-293.
Summa-Sorgini C, Fernandes V, Lubchansky S, et al. Errors associated with IV infusions in critical care. The Canadian journal of hospital pharmacy. 2012;65(1):19.
TJC. Sentinel Event Alert: Managing risk during transition to new ISO tubing connector standards. In. Vol 53: The Joint Commission; 2014.
Whittle SN, Horton-Deutsch S. Reducing the Second Victim Phenomenon: Healing Our Healers With Caritas Coaching. Holistic nursing practice. 2019;33(6):360-365.
Wolf ZR, Hughes RG. Best practices to decrease infusion-associated medication errors. Journal of Infusion Nursing. 2019;42(4):183-192.
Wu AW, Shapiro J, Harrison R, et al. The Impact of Adverse Events on Clinicians: What's in a Name? Journal of patient safety. 2020;16(1):65-72.
