Intravenous Fluid Management in Critically Ill Adults: A Review

Analysis of the Integrated Management Model of Medical Care and Medication in Intravenous Treatment for Critically Ill Patients

Objective

To explore the effect of the Integrated Management Model of Doctor-Nurse-Pharmacist Collaboration on the Safety of Intravenous Therapy in Critically Ill Patients.

Methods

1587 patients who were hospitalized in the Intensive Care Department of the Fourth Hospital of Hebei Medical University in China from January 2021 to December 2022 were selected. 768 patients before the implementation of the integrated medical, nursing, and drug management model were selected as the control group, and 819 patients who implemented the integrated medical, nursing, and drug management model were selected as the observation group.

Results

Compared with the control group, the incidence of drug compatibility contraindications in the observation group decreased from 3.5% to 1.5% (χ2=6.957 P=0.008), the central venous catheter (CVC) blockage rate decreased from 2.5% to 1.0% (χ2=5.249 P=0.022), the daily incidence of catheter related bloodstream infections decreased from (1.84 ± 2.17) to (0.91 ± 1.19)(t=6.988 P=0.015), and the incidence of peripheral venous treatment related complications decreased from 10.3% to 2.9% (χ2=16.663 P=0.000). Among them, the incidence of phlebitis decreased from 5% to 1.6% (χ2=4.817 P=0.028). The incidence of drug exudation decreased from 3.4% to 0.8% (χ2=0.031 P=0.019). The incidence of extravasation has decreased from 2.5% to 0.4% (χ2=0.044 P=0.027). The differences were statistically significant (P<0.05).

Conclusion

The Integrated Management Model of Doctor-Nurse-Pharmacist Collaboration significantly reduced the incidence of catheter-related bloodstream infections (CRBSI), drug incompatibility, and other intravenous therapy-related complications, thereby enhancing the safety of intravenous therapy in critically ill patients.

Reminding staff of diligence during the medication process is not enough to ensure safety: Learning from wrong fluid product selection incidents in the care of critically ill patients

Background and objectives

Wrong fluid product selection may cause harm to patients. This study aimed to describe voluntarily reported wrong fluid product selection incidents, including their consequences, the reported latent conditions and active failures leading to these and the suggested safeguards to prevent their occurrence, and to compare the suggested and literature-based safeguards to improve the fluid therapy safety within the intensive care (ICU) environment.

Methods

All voluntarily and anonymously reported wrong fluid product selection incidents in all Finnish ICUs during 2007–2017 were reviewed. The incident reports included categorized data that were analyzed quantitatively, and narratives that were analyzed qualitatively, using content analysis. The results were reported as frequencies and percentages and described by using Reason's model of human error.

Results

Over the eleven years, one wrong fluid product selection incident was reported every six days (n = 663; 584 errors, 79 near misses); most were reported to have occurred during the dispensing/preparing phase (92%). Of the 584 reported selection errors, a quarter (26%) was reported to have caused consequences to patients, and one third (35%) to have required corrective or monitoring actions. The main reported latent conditions to the incidents were Working environment and resources (e.g. workload and time pressure) (29%), Similar-looking and -sounding names or shared features of the product containers (i.e. the LASA phenomenon) (28%) and Working methods (22%); and the main reported active failures were a lack of concentration, or forgetfulness (26%). Some usable suggestions of safeguards were made, e.g. optimizing fluid storage (15%) or utilizing checking practices (21%). While requiring accuracy, i.e. reminding staff of diligence and to be more attentive to detail during the whole medication process, was emphasized in most reports (71%), involving manufacturers in redesigning labels of fluid products, utilizing technology and strengthening pharmacy services are advocated existing literature.

Conclusions

Wrong fluid product selection incidents with various latent conditions and active failures were reported more than once a week. To minimize the serious LASA phenomenon, multi-professional collaboration, coordinated international discussion and agreements of solutions with manufacturers, regulators and end-users, are needed. However, work is also needed to reduce the other latent factors, such as Working environment and resources as well as cognitive biases in daily work that may contribute to the occurrence of LASA related errors.