Safe implementation of standard concentration infusions in paediatric intensive care

Objective: To evaluate safety, following introduction of standard concentrations of morphine infusions in paediatric critical care.

Methods: Implementation: A multidisciplinary team was convened, and several workstreams designated, including derivation of concentrations, manufacturing, supply, prescribing, administration using smart pump technology, training and evaluation. Safety Evaluation: Retrieval of all existing data on medication errors linked to morphine use using our hospital incident reporting system and risk assessment of errors in relation to standard concentration implementation.

Key findings: The pilot identified several areas for improvement, stock control, reasons for reverting from standard to variable concentrations and sources of error. Improvements included the following: refining morphine concentrations and weight limits for bands, pump reprogramming and education. Long-term Safety: Over an 8-year period, 126 morphine-related incidents occurred (two-thirds in the 3 years around introduction). Of note, 67% (85/126) resulted in no patient harm; the remainder 33% resulted in low harm. Analysis of administration errors revealed that up to 70% could be eliminated by refining technology to include bar coding. These included the following: wrong syringe selection (24%), wrong pump mode (28%) and wrong patient weight inputted (18%).

Conclusion: Introduction of standard infusions is safe and effective. We are exploring ways to further refine safety and extending to other drugs.