Creating a Drug Library for Zero Continuous Infusion Errors in a Paediatric Intensive Care Unit: A Quality...

Area of Science:

• Patient Safety
• Quality Improvement
• Healthcare Systems Engineering

Background:

• Medication errors during continuous infusions in paediatric intensive care units (PICUs) pose significant risks.
• A sentinel event involving a severe ketamine overdose highlighted the need for intervention.

Purpose of the Study:

• To evaluate a systems-based solution for reducing continuous infusion errors in PICUs.
• To improve patient safety through a multidisciplinary approach.
• To enhance staff compliance, satisfaction, and perceived safety.

Main Methods:

• Root cause analysis (RCA) and human factors engineering (HFE) were employed.
• Interventions included smart infusion pumps with a customized drug library integrated with the EPIC electronic medical record (EMR) system.
• A Plan-Do-Check-Act (PDCA) cycle guided implementation, involving staff training and standardized medication preparation.

Main Results:

• Zero medication errors were reported from October 2024 to January 2026.
• Staff satisfaction and perceived safety improvements exceeded 95% in post-implementation surveys.
• The successful model was scaled to the emergency department and five subspecialty wards.

Conclusions:

• The intervention effectively minimized continuous infusion errors, fostering a culture of high reliability and zero harm.
• Ongoing education, adherence to double-checking protocols, and EMR enhancements are recommended for sustained improvement.
• This scalable model offers a framework for reducing errors in other high-risk clinical settings.