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Evaluating the Impact of an Intravenous Workflow Management System on Error Detection During Sterile Compounding
Thursday April 24, 2025 11:00am - 11:15am EDT
Olympia 1
Title:
Evaluating the Impact of an Intravenous Workflow Management System on Error Detection During Sterile Compounding
Authors:
Alex Kwan, Christopher Duphren 
Objective:
To evaluate the error detection rate and error types between products prepared without technology and those with IVWMS. 
Self Assessment Question:
Does the use of IVWMS increase the detection of errors during IV compounding, True or False?
Background: 
            Intravenous (IV) medication errors remain a significant patient safety concern, with manual preparation error rates reaching up to 37% for complex solutions. To mitigate this, hospitals are adopting IV workflow management systems (IVWMS), which utilize barcode scanning and volumetric verification to enhance error detection when verifying compounding sterile products (CSP). Studies have shown that IVWMS detect errors at significantly higher rates than manual processes and eliminate incorrect drug errors. Despite these benefits, adoption is limited; only 24.7% of larger hospitals had implemented such technology by 2017. The Institute for Safe Medication Practices (ISMP) emphasizes the importance of these technologies for improving IV preparation safety. This study aims to evaluate the implementation of an IVWMS at a tertiary hospital to assess its impact on compounding accuracy and efficiency. 
Methods:
            This single-center, prospective study with retrospective data collection aims to assess the impact of an IVWMS on reducing medication errors during IV medication preparation in a hospital setting. The primary objective of this study is to evaluate the error detection rate and error types between products prepared without technology and those with IVWMS. The secondary objective was to evaluate the benefit of IVWMS between adult and pediatric IV doses. Compounded sterile products produced at the inpatient pharmacy of Wellstar MCG and the Children’s Hospital of Georgia two weeks before and after the implementation of IVWMS were evaluated. Compounded chemotherapy, parenteral nutrition, and renal replacement therapy were excluded. Pharmacists were given a standard data collection form and instructed to record errors identified during compounding before IVWMS. Post-IVWMS error detection reports were generated from the software and analyzed. Errors were defined as deviations from the details on the patient label or institutional CSP preparation policies. Descriptive statistics, including means, medians, and frequencies, will be used to characterize the data and compare pre- and post-implementation groups to assess the impact of the IVWMS.
Results:
The total number of IV doses prepared before and after the implementation of the IVWMS were 2818 and 3183, respectively. IVWMS significantly enhanced error detection during intravenous medication compounding (n = 25, 0.89% vs. n = 281, 8.83%; p < 0.05). The top three error types before IVWMS were incorrect medication (32%), compounding method or technique issue (28%), and incorrect medication volume (24%). With IVWMS, incorrect medication was the most common error detected (92%). The types of errors detected were similar with IVWMS compared to without IVWMS across adult and pediatric populations. The frequency of errors detected for pediatric patients increased after the implementation of IVWMS (n = 13, 52% vs. n = 198, 70.5%).
Conclusion:
The large increase in post-implementation errors reflects the enhanced detection and documentation capabilities of the IVWMS. Compounding technique-related issues decreased post-implementation, which may suggest that IVWMS standardizes compounding practices. A significant implementation challenge identified was the need for frequent mixture record maintenance due to concurrent EHR transition, highlighting the importance of accurate master formula documentation for reliable barcode scanning verification. The use of IVWMS demonstrated improvement in detecting potential intravenous medication compounding errors, with a 10-fold increase in error detection. Study findings emphasize the critical importance of maintaining accurate mixture records within the IVWMS for optimal error detection. Future focus should include ongoing monitoring of IVWMS compounding records, regular updates to mixture records, and continued assessment of error patterns to optimize IVWMS effectiveness.


Moderators
avatar for Nadia Hason

Nadia Hason

Ambulatory Care Clinical Pharmacy Specialist, Kaiser Permanente
I\\'m an ambulatory care clinical pharmacy specialist and the clinical pharmacy intern coordinator at Kaiser Permanente. I also serve as a preceptor for the KPGA PGY-1 and PGY-2 programs.
avatar for Marci Swanson

Marci Swanson

Clinical Pharmacist Practitioner, Carl Vinson VA Medical Center
Presenters
AK

Alex Kwan

PGY2 Health-System Pharmacy Administration and Leadership Resident, Wellstar Medical College of Georgia Health
Alex Kwan was raised in Johns Creek, Georgia. He obtained his Doctor of Pharmacy degree at the Philadelphia College of Osteopathic Medicine in Suwanee, Georgia. He is the current PGY2 Health-System Pharmacy Administration and Leadership Resident at Wellstar MCG in Augusta, Geogia... Read More →
Thursday April 24, 2025 11:00am - 11:15am EDT
Olympia 1
  Administration (ADM), Wellstar MCG Health Medical Center
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