Evidence
Sāfen Medical product development, clinical use and implementation are evidence-based.
Sāfen Clinical Evidence Summary: The Problem
Medication Errors: Prevalence and Impact
91 study review found that 73% overall probability of making at least 1 error in IV therapy. Common medication groups associated with medical administration errors include nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antimicrobials.
An overall error rate of 14% was identified during the administering, documenting, and prescribing of IV infusion medication in an adult ICU. The mean number of errors per infusion order was 3.0. Up to 21 separate errors might occur in association with a single dose of an IV medication, and incorrect IV labels made up 31.5% of all errors.
For every added intravenous drug administered, the odds ratio for error increased by 1.03 in critical care settings.
The majority (24%) of the errors were related to medication labeling. 50% of the MEs led to an ADE and 50% were considered significant.
Although smart pumps offer numerous safety advantages, they are also prone to implementation and human factors problems, such as difficult user interfaces and complex programming requirements that create opportunities for serious errors.
The Costs of Medication Errors — Financial
Preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. It is estimated that inpatient preventable ADEs associated with injectable medications increase the annual US payer costs by $2.7 billion to $5.1 billion.
Lahue, Betsy J., et al. “National burden of preventable adverse drug events associated with inpatient injectable medications: healthcare and medical professional liability costs.” American Health & Drug Benefits 5.7 (2012): 1.
Sāfen Clinical Evidence Summary: The Problem
The Costs of Medication Errors — Emotional
Medication errors undermine staff confidence and detract from sense of safety in workplace.
“Physicians and other providers may feel a variety of adverse emotions after medical error, including guilt, shame, anxiety, fear, and depression.”
Robertson, Jennifer J., and Brit Long. “Suffering in silence: medical error and its impact on health care providers.” The Journal of emergency medicine 54.4 (2018): 402-409.
Sāfen Clinical Evidence Summary: The Solution
Sāfen Clinical Evidence Summary
This practice addresses a recognized risk point in the administration of medications in perioperative and other procedural settings. Labels for medications and medication containers are also addressed at Standard MM.05.01.09.
“National Patient Safety Goals® Effective January 2023 for the Hospital Program” The Joint Commission 2023.
A summary of 57 studies found key “systemic defense” for IV errors is standardization of the use processes for high-alert medications.
Kuitunen, Sini, et al. “Systemic causes of in-hospital intravenous medication errors: a systematic review.” Journal of Patient Safety 17.8 (2021): e1660.
This will further reduce the burden on clinicians to reconcile discrete infusion components (e.g., bag, pump, tubing) and use add-on components, like labels/ organizers, since components may be better associated to begin with (e.g., perceptual markers, physical proximity).
Pinkney, S., Fan, M., Chan, K., Koczmara, C., Colvin, C., Sasangohar, F., Masino, C., Easty, A., & Trbovich, P. (2014). Multiple Intravenous Infusions Phase 2b: Laboratory Study. Ont Health Technol Assess Ser, 14(5), 1-163. https://www.ncbi. nlm.nih.gov/pubmed/26316919
