Sexually Transmitted Diseases in Adolescents, Incompatibility of Intravenous Medications, Turnover Rates due to Burnout in Healthcare (24 hours)

Incompatibility of Intravenous Medications

Review of Literature

Errors associated with incompatible intravenous (IV) drugs among patients aged 65 years or more patients in ICU. Srisram et al. (2020) established that intravenous drug incompatibilities in ICU can be reduced by establishing pharmaceutical guidelines for administering IV drugs. The article provides high-quality evidence supported by results from 104 medication charts and analyzed through the Micromedex healthcare series. The evidence provided by this article applies to the PICOT question because supports pharmaceutical guidelines when administering IV drugs or reducing the rate of incompatibilities in the ICU. The finding is similar to those of other studies (Ertuna et al., 2019). The differences between the two studies were in data collection with Srisram et al. obtaining data from medical charts while Ertuna et al. (2019) obtained data from pharmacist medication review reports. There is no controversy in this article.

Machotka et al. (2015) identify real incidences of IV drug incompatibilities in the ICU and suggest that adhering to a few simple rules of IV drug administration can reduce these incidences. The article provided good-quality evidence as the conclusions revealed the prevalence of real-life incompatibility incidences in the ICU and were supported by the results obtained from the study conducted. The evidence is compatible with the PICOT question because it reveals that the rate of errors caused by the incompatibility of IV drugs is high. The findings are consistent with those of Fedaku et al. (2017). The major difference between the two studies is the type of data collected with Machotka et al. 2017 focusing on intravenous drug incompatibility errors while Fedaku et al. 2017 focusing on intravenous drug errors caused by wrong or missed doses. There is no controversy in this article.

Fekadu et al. (2017) associate intravenous drug errors with clinical complications that lead to undesirable results that can be prevented. The article provides good-quality evidence that leads to the conclusion that wrong or missed dose medication errors are prevalent in the emergency and intensive care units. The evidence applies to the PICOT question as it suggests that intravenous drug errors caused by wrong or missed doses should be addressed to reduce the rate of these errors. The evidence provided by the authors is consistent with the findings of Machotka et al. (2017). The difference between the two studies is that Fedaku et al. (2017) provide wrong and missed doses errors as the focus of the study while Machotka et al. (2017) focus on the physiochemical incompatibility of intravenous drugs as the cause of these errors. The controversy in this article is that when other studies discuss intravenous drug incompatibility, it discusses dose errors in ICU.

Ertuna et al. (2019) discuss drug-related problems (DRP) in older adults and associate these DRPs with complex medication regimes and the role pharmacist interventions play in reducing the rate of DRPs. (b) The article provides low-quality evidence that contrast with the other studies as it provides inadequate evidence to support DRPs in elderly patients caused by increased drug use. Evidence produced by this article is relevant to the PICOT question because it addresses the rate of errors caused by drugs used by older adults. The similarity between these articles with Srisram et al. (2020) is that both articles consider pharmacist guidance as an effective intervention for intravenous drug errors. While Srisram et al. (2020) consider pharmaceutical guidelines as an effective solution to intravenous drug errors, Ertuna et al. (2019) consider pharmacists' intervention as the ultimate solution. The controversy observed in this article is that it proposes 329 interventions to reduce the rate of drug errors while other studies propose one or two interventions.

Hanifa et al. (2018) explore the increase in the rate of intravenous incompatibility due to the use of a single intravenous line in the pediatric unit. The article provides high-quality evidence to show that the use of a single intravenous line to administer multiple drugs increases the rate of incompatibility medication errors. The evidence applies to the PICOT question since it shows the impact of incompatible drug administration using a single intravenous line on the rate of medication errors. The similarity between this article and Mosopefoluwa et al. (2019) is that both consider the co-administration of intravenous drugs as a major cause of incompatibility. The main difference between the two studies is that Hanifa et al. (2018) focus on the pediatric intensive care unit (PICU) while Mosopefoluwa focuses on the general intensive care unit (ICU). The controversy in this article is that it states that there is limited evidence to show patterns of concurrent medication use utilizing a single intravenous line but concludes that this type of drug administration is common practice.

Vijayakumar et al (2019), relates intravenous drug administration of two or more incompatible drugs with the rate of drug-related problems (DRPs) in hospitalized patients. The article’s evidence is of good quality because the study is conducted using a sizeable sample of 110 patients and the results led to a conclusion that simultaneously administering two or more incompatible drugs intravenous increases the rate of errors in ICU. The findings in this article apply to the PICOT question because they discuss the rate of errors impacted by intravenous drug incompatibilities. The evidence in this article is similar to Hanifa et al. (2019) study findings. The main difference is that Vijayakumar et al. (2019) do not focus on a single hospital or country where the study was conducted while Hanifa et al. (2019) include a single location where the study was conducted (Indonesian hospital). There was no controversy identified in the article.

The study conducted by Assefa et al. (2020) discusses the polypharmacy and drug-drug interactions (DDIs) experienced by older cardiovascular patients due to multiple drug therapy required to manage cardiovascular diseases. The article provided high-quality evidence supported by the identification of 850 potential DDIs which reduces the risk of bias in the article. The findings in this article apply to the PICOT question because they show the risk posed by DDIs due to drug incompatibility in older patients. The similarity between the articles is that they conducted cross-sectional studies. The difference between Assefa et al. (2020) article and Ertuna et al. (2019) is that while the former does not suggest an intervention strategy the latter proposes pharmacist intervention as a solution to drug-related problems such as drug-drug interactions. There was no controversy identified in this article.

Sabzi et al. (2019) establish a connection between medication errors and healthcare complexities such as hospital management and work environment among other nurse work dynamics. The article provides low-quality evidence that associates the nurse work environment with the rate of medication errors therefore a high risk of bias. The findings of this article are slightly applicable to the PICOT question because they focus on work dynamics and the role they play in the rate of medication errors. This study is similar to other studies because it conducts a cross-sectional study. The major difference between this article and other articles is that this article focuses on work dynamics as a source of medication errors while others focus on drug incompatibility as the cause of medication errors in hospitals. The controversy in this article is that it generalizes the results conducted from a single hospital to suggest that work conditions irrefutable increase or reduce the rate of medication errors.

Mendez et al. (2018) established that to identify drug incompatibility errors, it is crucial to consider the types and frequency of errors that occur during drug preparation and administration. The evidence provided by this article is of good quality and shows that intravenous drug errors are of different types and are very frequent during preparation and administration. The applicability of the evidence in this article to the PICOT question is that it focuses on incompatibility medication errors that occur during drug administration. The similarity between this article and Fekadu et al. (2017) is that both conduct a hospital-based cross-sectional study on intravenous drug incompatibility. The difference between the two studies is that Mendez et al. (2018) focus on both types and frequency of these errors while Fekadu et al. (2017) focus only on the frequency (prevalence) of drug administration errors.While other studies focused on the drugs administered, this article focused on hand hygiene during drug preparation and asepsis materials during infusion.

Oduyale et al. (2019) reveal that multiple intravenous drugs can be administered using the same IV catheter as long as there is drug compatibility the article provided low-quality evidence by generalizing results obtained from twenty nurses and two hospitals in the same location in England. The evidence applies to the PICOT question because it explores drug compatibility as an effective solution to medication errors caused by intravenous drug administration using the same lumen of an IV catheter. The similarity between this article and Hanifa et al. (2018) is that both articles discuss the co-administration of multiple intravenous drugs through a single infusion line. The article is different from Hanifa et al. (2018) because it collects data through focus group interviews while the other uses a mixed model design. There was no controversy discovered in this article.

Knowledge directly to PICOT question

The rate of errors due to incompatibility of intravenous medication can be reduced by implementing a nurse-training program that is based on the interventions suggested in the articles. A nurse-training program will enable nurses to reduce the rate of errors they cause when they administer incompatible intravenous drugs using the same infusion line. The program will also focus on the numerous interventions proposed by the ten articles to reduce the rate of errors. They will also be able to identify the types of errors caused by drug incompatibilities and the frequency in which they occur, enabling them to form evidence-based interventions to reduce the frequency of these errors (Mendez et al., 2019).

Oduyale et al. (2018) propose administering multiple intravenous drugs that are compatible using the same lumen of an IV catheter. The article insists on assessing and managing the compatibility of intravenous drugs since co-administration of intravenous drugs in ICU is common practice and elderly patients aged 65 years and above often require multiple drug therapy and few infusion lines. Vijayakumar et al. (2019) highlight the importance of forming effective strategies for reducing the rate of errors due to the incompatibility of intravenous medications because these errors cause drug-drug interactions among other drug-related problems that affect elderly patients. The strategies proposed in these two studies help reduce medication errors and when implemented properly with adequate nurse training can improve the safety of patients aged 65 years and above in ICU (Vijayakumar et al., 2019).

Practice Change

Implementing an eight-week nurse training program using Watson's caring theory reduced the rate of errors caused by intravenous drug incompatibility. This is because nurses can assess and manage drug compatibility in ICU during the preparation and administration stages. Subsequently, a nurse-training program provided nurses with evidence-based practice knowledge on compatible drugs and their compatible conditions or proportions. A nurse training program will also equip nurses with drug preparation knowledge and skills to utilize a single or few infusion lines that elderly patients (65 years and above) have because the drugs cannot be administered orally (Mendez et al., 2019).

Objective

The objective of implementing eight nurse training programs is to reduce the rate of errors caused by the incompatibility of intravenous drugs. Reducing the rate of these errors will lead to positive or better patient outcomes since these errors lead to patient morbidity and mortality due to drug-related problems and clinical complications. The implementation of the proposed problem change aims at improving patient safety and reducing the rate of mortality and morbidity in elderly patients caused by incompatibility that is preventable through a nurse-based intervention. The problem change also focuses on improving patient quality of life and increasing recovery rate by preventing medication errors caused by incompatibility during and after drug administration (Assefa et al., 2020).

Problem exists

The issue of medication errors due to the incompatibility of intravenous medication is prevalent in intensive care units since there are limited drug infusion lines, especially in elderly patients who require multiple drug therapy to manage serious health issues such as cardiovascular diseases. ICU patients cannot take medication orally; hence, limited infusion lines reduce the drug's effectiveness and can potentially cause adverse drug reactions. The proposition for change is to reduce nurse practice-based factors that lead to increased errors caused by incompatibility. The proposition also targets elderly patients since their high age is a risk factor for drug interactions due to the low metabolism rate associated with aging (Assefa et al., 2020).

Pros vs Cons

The benefits associated with a nurse training program focused on drug compatibility are reduced rate of errors caused by incompatibility, improved patient safety in ICU, reduced rate of mortality and morbidity caused by these errors, reduced cost of healthcare due to reduced hospitalization, and readmission rate, increased patients quality of life and recovery rate among others. The disadvantage presented by implementing a nurse-training intervention is the lack of time to attend the program due to heavy nurse workloads and high nurse-patient ratios that prevent nurses from pursuing other ventures such as nurse training programs. The current state of the rate of errors is moderate to high since there has yet to be a successful intervention implemented to reduce the frequency of these errors (Mendez et al., 2019).

Strengths and weaknesses of all the sources

The strength of Srisram et al. (2020) article is that it studies a 1000-bed ICU unit to draw objective conclusions. The weakness of this article is that it analyses the incompatibility of only two drug combinations and fails to observe clinical complications caused by these drug incompatibilities. The strength of Machotka et al. (2015) article is that the study lasts 12 months, a sufficient time to draw objective conclusions. However, the article presents challenges of ensuring that the studies are blind which could present a bias.

The strength of Fekadu et al. (2017) is, in addition to errors caused by the incompatibility of intravenous drugs, it explores errors due to wrong and missed doses of these drugs. The limitation of this study is that it was conducted in one center with a small sample size. The strength of Ertuna et al. (2019) is that it proposes that pharmacists be part of the intervention. The limitation of this study is that it has limited resources and time to evaluate the interventions.

The strength of Hanifa et al. (2018) is it explores a different patient population to show that drug incompatibility can occur in other units. However, the study is limited in that fails to consider and observe the clinical implications caused by these errors. The strength of Vijayakumar et al. (2019) is that the article considers findings in hospitals in Germany, France, and the UK among other countries to provide evidence with little to no bias. The weakness of this study is that it was conducted inwards instead of in ICUs where these types of medication errors are prevalent.

Assefa et al. (2020) strongly point out how drug-drug interactions caused by the incompatibility of two or more drugs affect elderly patients with cardiovascular. However, the article does not discuss drug incompatibility as a cause of DDIs in detail. Sarbi et al. (2019) focus on other causes of medication errors that affect the elderly such as nurse work conditions. However, the study fails to show significant differences in the rate of medication errors under diverse work dynamics.

Mendez et al. (2018) not only consider the type of errors in drug preparation and administration, but also the frequency in which they occur in the ICU. The study, however, was conducted in a single center with a small sample size. the strength of Oduyale et al. (2019) is that it proposes interventions that utilize the available resources. the weakness of this study is that it was conducted in two hospitals within the same critical care region therefore the results may not reflect the perspectives of ICU nurses in other areas.

References

Assefa, Y. A., Kedir, A., & Kahaliw, W. (2020). Survey on polypharmacy and drug-drug interactions among elderly people with cardiovascular diseases at yekatit 12 hospital, Addis Ababa, Ethiopia.  Integrated Pharmacy Research & Practice,  9, 1. https://doi.org/ 10.2147/IPRP.S231286

Ertuna, E., Arun, M. Z., Ay, S., Koçak, F. Ö. K., Gökdemir, B., & İspirli, G. (2019). Evaluation of pharmacist interventions and commonly used medications in the geriatric ward of a teaching hospital in Turkey: a retrospective study.  Clinical Interventions in Aging,  14, 587. https://doi.org/10.2147/CIA.S201039

Fekadu, T., Teweldemedhin, M., Esrael, E., & Asgedom, S. W. (2017). Prevalence of intravenous medication administration errors: a cross-sectional study.  Integrated pharmacy research & practice,  6, 47. https://doi.org/ 10.2147/IPRP.S125085

Hanifah, S., Ball, P., & Kennedy, R. (2018). Medication incompatibility in intravenous lines in a Paediatric Intensive Care Unit (PICU) of Indonesian hospital.  Critical Care & Shock,  21(3).

Machotka, O., Manak, J., Kubena, A., & Vlcek, J. (2015). Incidence of intravenous drug incompatibilities in intensive care units.  Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub,  159(4), 652-6.

Mendes, J. R., Lopes, M. C. B. T., Vancini-Campanharo, C. R., Okuno, M. F. P., & Batista, R. E. A. (2018). Types and frequency of errors in the preparation and administration of drugs.  Einstein (São Paulo),  16. https://doi.org/10.1590/S1679-45082018AO4146

Oduyale, M. S., Patel, N., Borthwick, M., & Claus, S. (2020). Co‐administration of multiple intravenous medicines: Intensive care nurses' views and perspectives.  Nursing in Critical Care,  25(3), 156-164.

Sabzi, Z., Mohammadi, R., Talebi, R., & Roshandel, G. R. (2019). Medication Errors and Their Relationship with Care Complexity and Work Dynamics.  Open Access Macedonian Journal of Medical Sciences,  7(21), 3579.

Sriram, S., Aishwarya, S., Moithu, A., Sebastian, A., & Kumar, A. (2020). Intravenous drug incompatibilities in the intensive care unit of a tertiary care hospital in India: Are they preventable?.  Journal of Research in Pharmacy Practice,  9(2), 106.

Vijayakumar, A., Sharon, E. V., Teena, J., Nobil, S., & Nazeer, I. (2019). A clinical study on drug-related problems associated with intravenous drug administration.  Journal of basic and clinical pharmacy,  5(2), 49.