McSweeney Julia, Rosenholm Emily, Penny Katherine, Mullen Mary P, Kulik Thomas J
Julia McSweeney, Emily Rosenholm, and Katherine Penny are nurse practitioners, Cardiology Program, Boston Children's Hospital, Boston, Massachusetts. Mary P. Mullen is Associate Director, Pediatric Pulmonary Hypertension Program, Boston Children's Hospital, and Assistant Professor of Pediatrics, Harvard Medical School, Boston. Thomas J. Kulik is Director, Pediatric Pulmonary Hypertension Program, Boston Children's Hospital, and Assistant Professor of Pediatrics, Harvard Medical School.
Crit Care Nurse. 2019 Aug;39(4):e1-e7. doi: 10.4037/ccn2019651.
Pulmonary hypertension is a rare, life-threatening disease with limited therapeutic options and no definitive cure. Continuous intravenous prostacyclin therapy is indicated for treatment of severe disease. These medications have a narrow therapeutic index and a brief half-life; therefore, administration errors can be lethal.
To reduce medication errors through an inpatient program to improve, standardize, and disseminate continuous intravenous prostacyclin therapy practice guidelines.
Data were collected from the electronic safety reporting system of a single hospital to determine the number and types of continuous intravenous prostacyclin therapy errors that were reported over an 8-year period. A clinical database and hospital pharmacy records were used to determine the number of days on which hospitalized pediatric patients received the therapy.
A nursing-directed quality improvement initiative to enhance the safety of continuous intravenous prostacyclin therapy for pediatric patients was begun in January 2009. Efforts to improve safety fell into 4 domains: policy, process, education, and hospital-wide safety initiatives.
The number of therapy errors per 1000 patient days fell from 19.28 in 2009 to 5.95 in 2016. Chi-square analysis was used to compare the result for 2009 with that for each subsequent year, with values of .66, .35, .16, .09, .03, .12, and .25 found for 2010 through 2016, respectively.
The trend in reduction of continuous intravenous prostacyclin therapy errors suggests that proactive processes to standardize its administration, emphasizing both policy and education, reduce medication errors and increase patient safety.
