Applying root cause analysis to promote the medication safety of continuous drug infusions for infants

Abstract

An adverse medication event involving a continuous drug infusion dosage error was reported in the infant intensive care unit of our hospital in 2010. The causes of this adverse medication event were elicited in the healthcare network using root cause analysis. These causes included incomplete procedures and incorrect prescription, an incomplete procedure of medication in continuous drug infusion, complex procedures in confirming prescription, the transcription of doctor's orders and prescription (i.e., kardex), and deficient knowledge of medication procedures exhibited by clinical nurses. The main purpose of this project was to achieve a 100% completion rate for nurse administrations of continuous intravenous medication and zero adverse medication events. Strategies included simplifying the prescription verification process, establishing regulations for drug prescription, standardizing the steps required for continuous intravenous medication administration, developing the dosage criteria for continuous intravenous medication, and developing a double-check mechanism for high-risk medications. In addition, relevant nurse's continuous educational programs were provided to help nurses effectively implement drug administration. The completion rate for administering the medication steps has increased to 99% and the compliance rate for pediatricians' orders regarding medication prescription has increased to 96%. Furthermore, no additional adverse medication events were observed after the intervention. This project established a systemic drug administration mechanism to promote communication and cooperation among healthcare teams and further enhanced medication safety and quality for infants.