improving the safety of continuously infused fluids in the emergency department

R E S E A R C H P A P E R

Improving the safety of continuously infusedfluids in the emergency department

Junho Cho MDAssistant Professor, Department of Emergency Medicine, Inje University College of Medicine, Busan, Korea

Hyun Soo Chung MD PhDAssociate Professor, Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea

Seong Hee Hong RNUnit Manager, Department of Nursing, Yonsei University Gangnam Severance Hospital, Seoul, Korea

Accepted for publication April 2012

Cho J, Chung HS, Hong SH. International Journal of Nursing Practice 2013; 19: 95–100Improving the safety of continuously infused fluids in the emergency department

When an unexpected crisis happens to patients with multiple continuous infusion fluids in the emergency department(ED), nurses need to recognize specific medication promptly and accurately for appropriate action. This study aims toevaluate the efficiency of colour-coded label system in ED fluids during an uneventful crisis simulation event. Promptnessand accuracy of finding the correct fluid between the pre- and postintervention in each three groups (emergency nurses,intensive care unit nurses and nursing students) for three different scenarios (potassium, heparin and normal salinescenario) were assessed. Time improvement for all three groups from pre- to postintervention for all three scenarios werestatistically significant (P < 0.001). There were no incorrect fluids indicated by all three groups of participants atpostintervention analysis. Colour-coded labelling system in a simulated environment significantly improved the prompt-ness and accuracy of finding the correct fluid from multiple infused continuous fluids.

Key words: colour-coded, emergency department, emergency nurses, medication errors, simulation.

INTRODUCTIONSince the Institute of Medicine report in 1999,1 medica-tion errors have been an international concern in the hos-pital. Medication errors are responsible for the loss ofmore than 7000 lives annually in the United States.1 Anobservational study in the United Kingdom and Germanyfound a high rate of intravenous (IV) medication errors ofmoderate to severe significance.2 In a recent survey in

Korea, nurses responded medication error (69.5%) as themost contributing factor to patient safety risk.3

Although medication errors could occur in any partof the hospital, the emergency department (ED) has thepotential to be more vulnerable to medication errors.Estimates for ED adverse medication error events rangefrom 4% to 14%,4,5 but another report estimates havebeen as high as 53% to 82%.6 Recent study examined thefrequency, types, causes and consequences of voluntarilyreported ED medication errors in the United States.7 Thestudy reported an error rate of 78 per 100 000 visits,occurring most commonly in the administration phase(36%). It concluded by stating that ED medication errors

Correspondence: Hyun Soo Chung, Department of Emergency Medicine,Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu,Seoul 135-720, Korea. Email: [email protected]

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International Journal of Nursing Practice 2013; 19: 95–100

doi:10.1111/ijn.12022 © 2013 Wiley Publishing Asia Pty Ltd

might be a result of the acute, crowded and fast-pacednature of care. The unique environment and care systemof the ED provides many factors that might contribute tomedication error.8 Some of the main factors are multiplepatients being treated concurrently, frequent relianceon verbal orders, wide range of drugs in use, wide varietyof dangerous drugs, time pressures, interruptions/distractions and communication problems. Many effortshave been made to reduce medication errors in an acutesetting care.9–14 Labelling of high-risk drug infusions andlines is a well-recognized safety strategy for the preven-tion of medication errors.15,16 Recent studies report on theefficiency of colour-coded medication safety system inthe intensive care unit and the paediatric emergencyscenarios.17,18 Because of heavy overload of patients andincreased boarding time of critical patients in ED, multi-ple drug infusions are simultaneously and continuouslyinfused in a single patient. When an unexpected eventhappens, nurses need to recognize specific medicationpromptly and accurately in patients with multiple con-tinuous infusion fluids. Over the past two decades,growth in the use of simulation to attempt to improve thequality and safety of patient care has increased rapidly.19

The World Health Organization patient safety curriculumguide20 indicates that students learn better in a safe andsupportive environment where experiential learning isfacilitated. In such an environment, errors can be madewithout penalty, and mistakes can be allowed to proceedbeyond where they could in clinical practice, allowingthem to be instructive and their consequences addressed.Simulations can also give learners exposure and practiceexperience with rare, life-threatening patient problemswhere the presentation frequency is low whereas thestakes are high.21 This study aims to evaluate the efficiencyof colour-coded label system in ED fluids during anuneventful crisis event of a simulated critical patient. Wehypothesize that colour-coded label system in ED fluidswould improve promptness and accuracy in recognizingspecific medication fluids.

METHODSThis was a prospective, controlled, simulation study froma single academic tertiary care emergency centre of 30beds with an average of 45 000 annual visits. This studywas part of an ongoing quality improvement programmeof our centre. Therefore, the study was exemptedfrom the hospital’s institutional review committee.The ongoing quality improvement programme was an

initiative to improve and optimize the understanding ofpatient safety through simulation training.

A multidisciplinary team consisting of emergency phy-sicians, nurses and quality improvement officers wasformed. The team’s goal was to come up with a set of rarebut detrimental potential risks that could be encounteredin the ED. One of the potential risks was focused on thecritical patients that were boarded in the ED due to short-age of intensive care unit (ICU) beds. The risk analysis wasperformed by the team using the failure mode and effectsanalysis (FMEA) process.22 The top high-risk tasks result-ing from the FMEA process was administration anddelivery of continuous fluids with multiple medications.Potential failure modes identified were technical failure ofthe infusion pump, entering wrong rate on the pump,removing or connecting the wrong medication or wrongconcentration and using the wrong diluent or drug. Theteam then conducted a hazard analysis to calculate a riskpriority for each step to determine the likelihood ofpatient harm as a result of a failure. The team membersanalyzed each type of error for severity, frequency andprobability of reaching the patient. Each of these factorswas rated on a 10-point scale, where 10 was the mostsevere outcome. The criticality index for each error wascalculated by multiplying the score for each of the threefactors together. The highest criticality index receivedpriority for further analysis, which was removing or con-necting the wrong medication.

Based on the results of the FMEA, two main interven-tions were performed. First, all the lines and infusionpumps needed to be reorganized. Multiple fluids and linesof a single critical patient in the ED are tangled and mixedtogether, making it difficult to recognize the correct fluid.Therefore, the team utilized the colour-coded labellingsystem on the fluid bags, line and the infusion pump toreorganize the fluid and line arrangement. The secondintervention was to evaluate the efficiency of the colour-coded label system during an uneventful crisis event of acritical patient.

All the 25 nurses from the ED agreed to participate inthe study. Three nurses dropped out in the beginning ofthe study due to other personal commitments. Additional23 ICU nurses and 24 nursing students also participated inthe same study, making the total study population of 69.Their consent was received at the beginning of the study.

An in situ simulation imitating an ED bed was set up. Ahigh-fidelity mannequin was placed in the bed to mimicany physiological conditions related to the scenarios. The

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mannequin was connected to six different IV continuousfluids and lines. The fluids were five different medicationmixed fluids (potassium, heparin, bicarbonate, inotropic,vasopressor) and one non-medication mixed normalsaline fluid. They were all connected to an infusion pumpto control the infusion rate. Three different scenarioswere developed by the study team: (i) the nurse recog-nized that wrong dose of potassium was mixed and thefluid had to be found and stopped immediately; (ii) labo-ratory result showed prolongation of coagulation timemaking the nurse find the right fluid and stop it immedi-ately; (iii) the blood pressure of the patient dropped sud-denly and the physician ordered 200 mL of normal salinefluid to be infused immediately. When the participant wasdelayed or unsuccessful in finding the right fluid, the man-nequin physiologically displayed the adverse effect.

The study team agreed on the colour coding of eachfluid. The coding was as follows: blue for potassium, redfor heparin, green for bicarbonate, pink for inotropic,purple for vasopressor and dark grey border for normalfluid. After baseline assessment, all the nurses receiveda 1 h educational session on medication administrationerrors in a critical patient, the new colour-coded labellingsystem and simulation learning. The educational sessionwas run in six different time slots considering the nurses’different duty hours. The participants were given a periodof 1 week to memorize the colour codes.

The nurses were assessed in their promptness and accu-racy of finding the right fluid. Promptness was defined aslength of time the participating nurse took starting fromentering the simulated patient bay and ending when eitherthe infusion pump was stopped or the fluid line wasclamped or opened, depending on the scenario. Thelength of the time it took to complete the task was meas-ured by a stop watch in seconds. Accuracy was defined asfinding the correct running fluid according to the scenario,which were potassium mixed, heparin mixed and normalsaline fluid. The results were expressed with the numberof incorrect fluids indicated by the participants. Theexaminer was the unit manager of the ED. Twenty-twonurses in the ED, 23 nurses in the ICU and 24 nursingstudents were individually observed by the same exam-iner. They were each examined at baseline (preinter-vention) and after the colour-coded labelling systemapplication (postintervention). The colour-coded label-ling was done on the fluid bag, middle of the connectingline and at the end of the multi-connection apparatus.At the end of the study each participants were asked to

complete a preference survey using the 5-point Likert-type scale (1: least preferred; 5: most preferred).

DATA ANALYSISThe primary end-point was the difference in the prompt-ness and accuracy of finding the right fluid between thebaseline and postintervention observation in each threegroups (emergency nurses, ICU nurses and nursing stu-dents). With the assumptions of type I and type II error at0.05 and 0.2, respectively, and statistically meaningfultime differences in promptness at more than 5 s, the cal-culation shows that at least 16 participants are needed foreach group.17 Additional comparison was made in thepreferences of continuous fluid care between the pre- andpostintervention. Statistical analysis was performed withthe SPSS 12.0 (SPSS, Chicago, IL, USA). Continuousvariables were expressed in median. Non-parametricmethod, the Wilcoxon signed rank test was used to com-pare the pre- and postintervention. A value of P < 0.05was considered statistically significant.

RESULTSThe median years of experiences for the nurses in the EDand ICU were 4.2 and 5.0, respectively. The nursingstudents were all in their last fourth and final year ofschool and had not experienced their clinical clerkship inthe ICU nor ED. The experience with simulation learningwas variable, mostly (n = 43, 62%) between three andfive occasions of experience. Table 1 shows the result ofthe length of time it took for each participant group tocomplete each three scenarios. All three groups (emer-gency nurses, ICU nurses and nursing students) improvedsubstantially in promptness of recognizing the correctfluid for all three scenarios. The time improvement foremergency nurses from pre- to postintervention for thepotassium, heparin and normal saline scenario were 24.8–6.9 s (P < 0.001), 17.8–6.3 s (P < 0.001) and 19.2–6.3 s (P < 0.001), respectively. For the ICU nurses, thetime improvement from pre- to postintervention was22.4–5.1 s (P < 0.001), 17.8–5.4 s (P < 0.001) and18.6–4.9 s (P < 0.001), respectively for each scenario.And for the nursing students, the time improvement frompre- to postintervention for the potassium, heparin andnormal saline scenario were 58.9–9.0 s (P < 0.001),22.5–7.3 s (P < 0.001) and 32.0–6.9 s (P < 0.001),respectively.

Numbers of incorrect fluid indication are shown inTable 2. At baseline (preintervention), the incorrect

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numbers of fluid indicated by the emergency nurses, ICUnurses and nursing students were 2, 2 and 9, respectively.But there were no incorrect fluids indicated by all threegroups of participants at postintervention analysis.

All participants were asked to rate the feasibility orpreferences of the promptness and accuracy of multipleinfused fluids for the critically ill patients for the pre- andpostintervention process. The rating was done on a5-point scale, where 5 was the most preferred outcome.The results indicated that all three groups preferred thecolour-coded labelling system as a safer method of con-tinuous infused fluid care for the critically ill patients. Pre-and postintervention results for emergency nurses, ICUnurses and nursing students were 2.8–4.9 (P < 0.001),3.3–4.7 (P = 0.001), 2.2–5 (P < 0.001), respectively.

DISCUSSIONThis study showed that colour-coded labelling system is asafer method for caring of multiple continuous IV fluids ofcritically ill patients in the ED. This is an important issuefor a busy and chaotic environment such as the ED. Many

critically ill patients with multiple medication mixedfluids are boarded in the ED due to ICU bed shortages.Medication errors are prone to happen in this environ-ment. These errors might occur during any phase of thedrug delivery process (prescription → transcription →dispensing → administration → monitoring).23 But theadministration stage might be the last chance to employimportant safety checks to prevent a medication error.Unfortunately, many administration errors occur whencritical safety checks are ignored because there is a rush toadminister the drug in an emergency. The authors wantedto develop or validate a safe method for caring for IV fluidsin critical crisis events. This rare but detrimental eventwas chosen for the study team as one of the FMEA processanalysis due to the significant harm that is possible in theED environment. FMEA is a systematic, prospective risk-analysis process used to identify and assess the effects ofpotential errors or failures. Prospective risk managementactivities allow health-care facilities to minimize theoccurrence of errors, whereas a retrospective activity ana-lyzes errors after they have occurred. The goal of FMEA isto prevent errors by scrutinizing current system proc-esses.24 The authors recognized the potential risk of IVfluid administration process and proceeded with a pro-spective risk management activity to delineate the poten-tial harm before it reached the patient. This analysis alsogave us the chance to raise our voice for searching forimprovement in turnover rate of critical patient beds inthe ICU. After our FMEA report, the ICU committeestarted to discuss of a potential emergency ICU unit thatcould accommodate the overcrowding of critically illpatients in the ED.

The intervention was conducted through simulationlearning using a high-fidelity mannequin. Simulation hasbeen defined as a technique to replace or amplify real-patient experiences with guided experiences, artificially

Table 1 Promptness in recognizing the correct fluid (measurement in seconds)

ED (n = 22) ICU (n = 23) Student (n = 24)

Pre Post P-value* Pre Post P-value* Pre Post P-value*

K+ 24.8 6.9 < 0.001 22.4 5.1 < 0.001 58.9 9 < 0.001Heparin 17.8 6.3 < 0.001 17.8 5.4 < 0.001 22.5 7.3 < 0.001Normal saline 19.2 6.3 < 0.001 18.6 4.9 < 0.001 32 6.9 < 0.001

* P < 0.05. ED, emergency department; ICU, intensive care unit; K+, potassium.

Table 2 Accuracy in recognizing the correct fluid (number of

incorrect fluids)

ED (n = 22) ICU (n = 23) Student (n = 24)

Pre Post Pre Post Pre Post

K+ 1 0 0 0 3 0Heparin 1 0 2 0 0 0Normal saline 0 0 0 0 6 0

ED, emergency department; ICU, intensive care unit; K+,

potassium.

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contrived, that evoke or replicate substantial aspects ofthe real world in a fully interactive manner.21 In ourstudy, by setting up an in situ simulation, where the learn-ing environment is the actual working environment, wemade participants more immersive and motivated to thestudy. Also, by showing physiological presentations by themannequin during an incorrect fluid indication, the par-ticipants were able to learn and recognize what effectscould happen from their mistakes.

Because ICU nurses were familiar with caring for thecritically ill patients and multiple continuous infusedfluids, they were selected as a comparison group to theemergency nurses. The results showed that the colour-coded labelling system was just as easily learned andhandled by the emergency nurses as the ICU nurses. Theauthors also compared the study with the novice nursingstudent groups. The nursing students performed substan-tially worse than the nurses from both department onthe preintervention stage. This is an obvious reasonbecause the students were not exposed to the critically illpatients previously. But after the intervention, a signifi-cant improvement was shown, indicating that even novicepersonnel could benefit from a simulation learning of asafety issue in a hospital.

After the team reported and presented the study at thehospital’s annual quality improvement workshop, theyproactively went one step further to develop a new IVpole that could improve the care of continuously infusedIV fluids of a critically ill patient in the ED. Because of theovercrowding and limited space of ED, critically illpatients are sometimes moved from one space to anotherwithin the ED. Therefore, we wanted to develop a port-able IV pole that was capable of organizing the multiplefluids in a visually safer way (Fig. 1). There are limitationsin this study. First, this was a simulated study. Becauseof the rare circumstances of medication administrationerrors, and the difficulty of assessing the nurses duringactual working hours, a simulation study had to be usedfor analysis. We tried to create a safer learning environ-ment by setting up the scenario in one of the actual EDbed. The authors think this motivated the participants toperform better. Second, the colour-coding labellingsystem itself could contribute to a false safety for thenurses. We did not assess whether the labelling of thecolour code itself was correctly done or not. But webelieve that the study itself contributed to thinking proac-tively on the patient safety issue by the ED staff andfaculty.

CONCLUSIONSColour-coded labelling system in a simulated environ-ment significantly improved the promptness and accuracyof finding the correct fluid from multiple infused continu-ous fluids of a critically ill patient scenario. Although thisstudy does not indicate a completely ‘fail safe’ system, itgave the opportunity for the faculty and staff to proac-tively think and act for potential errors in an environmentlike the ED.

ACKNOWLEDGEMENTSThe authors wish to acknowledge the invaluable contri-butions made by all the nurses and students who partici-pated in the study. We would also like to express specialthanks to the nursing department and the quality improve-ment department for their support.

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Figure 1. Intravenous fluid pole developed by the study team.

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