1. Alexander, Mary MA, RN, CRNI(R), CAE, FAAN, INS Chief Executive Officer, Editor

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As we all know, medication errors and catheter-associated bloodstream infections can cause serious adverse outcomes, and sometimes death, for a patient in the hospital. For years, healthcare organizations such as The Joint Commission (TJC), the Agency for Healthcare Research and Quality (AHRQ), the National Quality Forum (NQF), the Institute for Safe Medication Practices (ISMP), and the Institute for Healthcare Improvement (IHI) have urged healthcare professionals to take steps to reduce and ultimately eliminate preventable infections and medication errors. Yet year after year, healthcare professionals make the same mistakes, and patients become sicker than they were when they went to the hospital. Sometimes they die.

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The publication of the Institute of Medicine's "To Err Is Human" in 2000 raised the level of awareness about hospital-associated infections and medication errors. The stunning number-perhaps as many as 98,000 dead each year as a result of medical errors-jolted the healthcare community, as well as the general public, into action.1 Consequently, healthcare organizations convened meetings, published papers, and shared recommendations for reducing errors. Infusion nurses focused on preventing catheter-associated bloodstream infections and IV medication errors. As time passed, however, the sense of urgency faded, and the issue disappeared from the headlines.


The federal government, however, was still paying attention. In 2000 the Institute of Medicine estimated that medical errors resulted in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwie.1 In response to these staggering losses, the federal government implemented a regulation that directed hospitals to change the way they provide care or lose federal reimbursements.2 As of October 1 of this year, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursements to hospitals when poor care results in a preventable illness not present at the time a patient was admitted to the hospital. Of considerable interest to infusion nurses is the fact that the costs of treating catheter-associated bloodstream infections will not be reimbursed if not present on admission.


Because this wholesale change in reimbursement practices affects every healthcare professional in every hospital in the US, we infusion nurses are back in emergency mode. This past summer, a number of healthcare safety organizations, including INS, took up the challenge to work toward the elimination of mistakes related to administering intravenous medications. The American Society of Health-System Pharmacists (ASHP), along with INS, ISMP, the US Pharmacopeia (USP), and the National Patient Safety Foundation (NPSF), convened an "IV Safety Summit" in July. INS, represented by President Cora Vizcarra, was the only nursing organization with membership on the Summit's Steering Committee. I attended the Summit as well, participating in various work groups.


After hearing testimony from expert panels and reviewing the recent research medication errors and prevention strategies, participants formed work groups and reported back with an action agenda.


Among the short-term and long-term actions we recommended were:


* Establish national standards for IV medication use in hospitals and health systems for the general adult patient population as well as specific populations and settings;


* Accelerate the process of FDA approval for new concentrations for existing drug products;


* Encourage the expanded use of intelligent infusion devices; create a mechanism that ensures that organizations are using these devices to their full benefit;


* Create and present a compelling business case for CEOs, leadership, and payers about the importance of IV medication safety, with a strong message that the organization cannot afford inaction on this issue;


* Require multidisciplinary patient safety training for physicians, pharmacists, and nurses, including experiential components during professional education, post-graduate work, and professional development activities;


* Establish a research agenda to answer questions and develop best practices.



The key to this important work is the continuation of collaborative efforts among the healthcare disciplines. INS is committed to continuing our role as a valued contributor to this initiative. Developing the action agenda is a necessary first step in addressing this critical issue of IV medication safety. Ongoing efforts must continue so that the cycle of repeating the same medication errors is broken. Our patients' lives depend on it!!


Mary Alexander




1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine/National Academies Press; 2000;1. [Context Link]


2. Centers for Medicare & Medicaid Services. Deficit Reduction Act of 2005. Accessed September 15, 2009. [Context Link]