Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting

Crit Care Med. 2019 Jul;47(7):e597-e601. doi: 10.1097/CCM.0000000000003790.

Abstract

Objectives: Assess interventions' impact on preventing IV infusion identification and disconnection mix-ups.

Design: Experimental study with repeated measures design.

Setting: High fidelity simulated adult ICU.

Subjects: Forty critical care nurses.

Interventions: Participants had to correctly identify infusions and disconnect an infusion in four different conditions: baseline (current practice); line labels/organizers; smart pump; and light-linking system.

Measurements and main results: Participants identified infusions with significantly fewer errors when using line labels/organizers (0; 0%) than in the baseline (12; 7.7%) and smart pump conditions (10; 6.4%) (p < 0.01). The light-linking system did not significantly affect identification errors (5; 3.2%) compared with the other conditions. Participants were significantly faster identifying infusions when using line labels/organizers (0:31) than in the baseline (1:20), smart pump (1:29), and light-linking (1:22) conditions (p < 0.001). When disconnecting an infusion, there was no significant difference in errors between conditions, but participants were significantly slower when using the smart pump than all other conditions (p < 0.001).

Conclusions: The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Female
  • Humans
  • Infusions, Intravenous / methods*
  • Infusions, Intravenous / nursing*
  • Inservice Training
  • Intensive Care Units / organization & administration*
  • Intensive Care Units / standards
  • Male
  • Medication Errors / prevention & control*
  • Middle Aged
  • Nursing Staff, Hospital / education
  • Nursing Staff, Hospital / organization & administration*
  • Nursing Staff, Hospital / standards
  • Simulation Training
  • Young Adult