Medication Errors and Hospital Infections Grossly Underreported

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The Infusion Nurses Society – India (INS), an independent coalition of academic healthcare professionals, has urged hospitals, voluntarily report errors due to infusion therapy

Bengaluru, Karnataka, May 13, 2014 -(PressReleasePoint)- The Infusion Nurses Society – India (INS), an independent coalition of academic healthcare professionals, has urged hospitals, voluntarily report  errors due to infusion therapy to its  national data repository center or website to help estimate the burden of infusion therapy complications occurring in hospitals.

Currently few hospitals have implemented surveillance mechanism, gradually more  hospitals will adopt the culture of safety  and report adverse outcomes, which will be vital to raise awareness, create benchmarks and institute the culture of self-improvement in order to minimize complications.
Under the initiative, INS will keep hospital data anonymous and will use data to help ascertain the magnitude of the problem and suggest a way forward.

Of all hospital acquired infection cases, a significant percentage can be attributed to unsafe infusion practices involving crucial life-saving IV administration of fluids, parenteral nutrition, drugs and blood products.

Hospital-acquired infections are caused by viral, bacterial, and fungal pathogens; the most common types are bloodstream infection, pneumonia (eg, ventilator-associated pneumonia), urinary tract infection and surgical site infection.

According to WHO, one in 10 patients is harmed while receiving hospital care. At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals. Medication errors are the most common type of error and account for 78% of serious medical errors in the ICU.

INS seeks to put error reduction strategies into high gear by re-evaluating and strengthening checks and balances to prevent errors.

Dr Prabhu Vinayagam, President, INS, said, “Infusion therapy, which is  intravenous introduction of a solution for therapeutic purpose is used on 90% of all hospitalised patients. However if unsafe infusion practices occur there is a chance that patients’ health may be compromised and even cause fatality. The issue becomes complicated especially with newborns as their immune system is often not fully developed. Often this happens due to lack of training of nurses in this area.”

Unsafe infusion practices compromise of faulty technique, incorrect dosage of drugs, selection of catheter sites, hand hygiene and may lead to complications such as swelling of veins (phlebitis), blood borne infections, blood clots and in extreme cases, death.

According to Mary Jose, Director, Nursing, Apollo Hospitals, Bengaluru, “Complications arising from unsafe infusion practice can have long term effects on patient care, patient satisfaction and length of stay. The risk factors can increase the overall cost to the hospital. Safe infusion practices, I.V cannulation, and its management should be a mandatory training for all the nurses as a part of their orientation.

INS has also suggested formation of a council similar to the National Coordinating Council for infusion & Medication Errors Reporting and Prevention in the US that examines and evaluates medication errors and recommends strategies for error prevention.

Said Dr Vinayagam, “It is a surprise that while US having world class health infrastructure still reports thousands of medication error cases, we at India seem to be oblivious to such cases. This is either due to lack of a reporting mechanism at institutional level and absence of adequate monitoring and regulation at the state level.”

INS urges health professionals, mainly nurses to report infections occurring at hospitals to their respective internal reporting programs and committees. Many infusion therapy complications are preventable if hospitals upgrade to new quality tools and adopt best medical practices.  
New concepts to safeguard patients from medication errors include use of computerized prescriber order entry system; a pharmacy system software to check screening of duplicate drug therapies and patient allergies; adopting use of electronic medication administration records (MAR) and bar coding.

The INS has also asked the public to be accountable and aware of medical procedures and complications. On World Nursing day, it has sought help of nurses to improve quality standards of administering medication to patients, while ensuring own safety, as patiens will be safe, only if healthcare professionals are safe. INS will launch national infusion guidelines and courses for nurses later this year at their 3rd annual conference.  
About INS India:
The Infusion Nurses Society–India, an international affiliate of the Infusion Nurses Society of the US, was formed in December 2010. The vision is to exceed the public’s expectations of excellence by setting standards for infusion care by developing and disseminating standards of practice, providing professional development opportunities and quality education, advancing the specialty through evidence-based practice and research supporting professional certification and advocating for the public, in alignment with the vision and mission of The Infusion Nurses Society of US.

About INS US:
INS is a not for profit organization dedicated to the specialty practice of infusion nursing. It was founded 40 years ago to support infusion healthcare professionals by providing them educational programs, establishing standards of practice, and disseminating research through the peer-reviewed publication of INS called the “Journal of Infusion Nursing.” INS has over 7,000 members in 39 different countries, and 3,300 nurses certified in infusion nursing.

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