Nurses, clinicians, and caregivers across the globe are busier and under more stress than ever before. Every day, they are expected to provide increasingly high-quality care while their resource levels remain woefully inadequate. When managing a high volume of patients, nurses face constant physical and mental strain that can quickly lead to burnout, in a space where even minor clinical errors can be harmful, even fatal.
“Infusion confusion” is one such error. In plain terms, infusion confusion is a tangled mess of IV lines that complicates care and impacts patient safety. The sheer volume of IV lines in a single patient can be overwhelming. On average, a patient in the ICU has an average of 8 IV lines at any one time, though the number can be upwards of 15+ given certain situations. Patients have multiple lines for the dedicated administration of pain medications, antibiotics, those that control central venous pressure, and hydration – each with different schedules and dosages. But then there are the up-to-additional 17 intermittent drugs a day that need a method to be administered without coming into contact with another drug. Enter the Keep Vein Open (KVO) line, which flows saline as a carrier for these “as-needed” drugs.
Nurses must not only monitor and navigate these lines for drug administration, but also quickly troubleshoot issues like line obstruction, dosage, and routine cleaning – all while avoiding an Adverse Drug Event (ADE). Needless to say, the time spent labeling lines for correct identification, tracing lines, checking orders, and administering drugs are both high-volume and, unfortunately, very error-prone.
Medical errors taking heavy toll on patients and providers alike
The size of this issue is astounding. According to a 2018 study from Johns Hopkins, more than 250,000 people in the United States die every year because of medical mistakes, making it the third leading cause of death after heart disease and cancer. In 2022, there were over 1.25 million serious infusion drug adverse events reported and nearly 175,000 deaths.
Around 60-90 percent of all IV infusions in the United States contain one or more errors, 56 percent of all ADEs are infusion-related and 26 percent of them are life-threatening. More than 15 percent of infusion ADEs are “wrong route” errors where the right drug is injected into the wrong line.
Delivery of a single medication dose to an individual patient requires the correct execution of 80 to 200 individual steps. For every IV line after the first one, a 3 percent compound error rate is present; with an average of 8 IV lines in the ICU, this is a 21 percent error rate. With more patients and fewer nurses, compounded by the “Great Attrition” in healthcare whereby 19 percent of nurses were lost in 2021 following COVID-19, line tracing needs to be faster, less tasking, and less error-prone.
Beyond the effects on patients and providers, medical errors can have a significant impact on organizations – and the healthcare market as a whole. On average, healthcare providers are paying $450,000 in avoidable direct ADE costs per year per 100 beds in the hospital. This is from direct costs and does not factor in labor, or patient harm liability suits. Industry-wide, infusion-related errors are estimated to add $2 billion annually to U.S. healthcare costs.
Lack of standardization for IV-line identification poses major challenges
Current methods to identify lines are time-consuming, lack standardization, and commonly involve the improvised use of labels and medical tape while not being in compliance with the governing standards from the Infusion Nurses Society. While these efforts do make some improvements to the IV identification and line tracing, it is still far from adequate as noted from the current error rates.
The current tape and label method makes it extremely difficult and cumbersome for caregivers to apply the labels to each line, repeat this process every time that lines are replaced per guidelines, and quickly distinguish and trace between the numerous infusion lines. The lines often become easily entwined, reflecting the notion of “spaghetti syndrome.” Shift-changes between day and night, new or traveling nurses, and interdepartmental transport all make these issues pervasive and unsolved today.
It is also dangerous for patients. As the clinician is tracing with their fingers to find the KVO line flowing saline, they can unintentionally jump from the correct KVO line to a different IV Line flowing a dedicated drug. The right drug mistakenly injected into the wrong line can have lethal consequences and is considered a “wrong route” infusion ADE. If a low impact event, this could be as minor as inflamed soft tissues, or more severe – it leads to a wrongful death.
So, how can we simplify our nurses’ lives and help the healers heal? There have been great advances in healthcare technology and innovation over the years. Smart infusion pumps and labeling systems with clear visual cues can help simplify line management, prevent patient harm, help the bottom line, and reduce the cognitive load on nurses.
Simple solutions for infusion line identification
Research has long shown the significant potential for light-linking solutions to enhance infusion patient safety in acute care settings (“Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting”, Crit Care Med. 2019 Jun 14). Novel solutions such as MedLite ID Smart-Lite are designed to prevent “infusion confusion” by simplifying the current line-tracing process and reducing the chance of IV line-tracing errors leading to wrong-route ADEs. The eight-time patented solution is a simple-to-use, disposable lighting solution that assists nurses in identifying and illuminate lines in all light settings accurately and efficiently.
Common use cases selected by hospitals have included the identification of the KVO line to allow hospital-wide standardization throughout the enter intradepartmental journey, in all lighting conditions. Typically, MedLite ID can be rolled out to a hospital in less than half a day. A current standard of care multi-minute procedure can be done with MedLite ID in less than 60 seconds while providing a simplified workflow, less mental task load, and a reduction in error potential. This smart yet simple solution has the potential to virtually eliminate wrong-route infusion IV line-tracing errors that lead to significant budget impact as well as liability exposure.
Clinical studies underscore potential benefits
A recent peer-reviewed article in the Journal of Infusion Nursing (JIN), the official publication of the Infusion Nurses Society (INS), provided statistically significant evidence that the MedLite ID Smart-Lite system was faster to access the primary medication line injection port and quantified as less mentally tasking. The article details a recent study conducted at Wake Forest University School of Medicine that found light-linking technologies such as MedLite ID are poised to contribute to improved patient safety and efficiency by reducing infusion line-tracing errors in critical care environments.
The research was conducted at the high-fidelity simulation suite at Wake Forest University School of Medicine with experienced intensive care unit (ICU) nurses. When compared to standard labeling practices, MedLite ID was 24 percent faster in accessing the primary medication line injection port and 40 percent less mental tasking as quantified within the study. The research also reinforced the device’s potential to prevent infusion errors — especially in low-light ICU conditions, where MedLite ID had zero errors compared to standard methods.
Embracing innovation will improve patient safety & the bottom line
Patent safety solutions such as MedLite make high-volume, high-cost, high-error issues such as infusion ADE better. When a life-saving drug needs to be administered, or even the routine intermittent medication, every minute matters while preventing avoidable “right drug, wrong IV line” errors. The harmed patient is one of two victims, the second victim being the nurse-hero that intended to do no harm. Often caregivers that harm a patient suffer from PTSD of the event.
Our healthcare system depends upon nurses and their ability to work safely and effectively. Behind every caregiver managing a multitude of IV lines is a patient depending on their diligence. MedLite ID can help remedy “infusion confusion” once and for all. We must prioritize our healthcare providers and invest in new simple but powerful solutions that inspire the safest and highest quality patient care.
Editor’sNote: Rodney W. Schutt is the President & CEO of Orion Innovations, a healthcare technology platform company advancing smart, simple, and patented solutions that improve patient safety and enhance the bottom line.