Infusion Medication Error Reduction by Two-Person Verification: A Quality Improvement Initiative

Area of Science:

• Medical Safety
• Quality Improvement
• Pediatric Anesthesia

Background:

• Intravenous medication errors pose significant risks to patient safety.
• The use of medication infusion pumps is increasing in hospital settings.
• Accurate programming of infusion pumps is critical for safe medication administration.

Purpose of the Study:

• To enhance medication safety by implementing a two-person verification system for infusion pump programming.
• To reduce errors associated with intravenous medication administration.
• To improve the overall safety culture within a pediatric hospital setting.

Main Methods:

• A quality improvement initiative was conducted in a tertiary pediatric hospital's anesthesia radiology imaging service.
• Interventions included educational meetings, reminders, visual aids, and continuous feedback.
• Data were collected and analyzed using run charts and statistical process control methods over 24 plan-do-study-act cycles.

Main Results:

• The rate of two-person verification for infusion pump programming increased from 0% to a sustained 90%.
• Four medication errors were identified and rectified before patient administration.
• No delays in case starts were observed, with over 90% efficiency maintained.

Conclusions:

• A brief two-person verification process effectively reduces medication errors from infusion pump programming.
• The implementation, utilizing plan-do-study-act cycles, demonstrated significant impact on patient safety.
• This initiative contributes to a robust hospital safety culture and reduced medication errors.