Presentation
A Human Factors Approach: Enhancing Safety for Intravenous Acetylcysteine Administration
DescriptionAcetaminophen overdose is a serious safety concern that often results in patients requiring hospitalization for treatment. Acetylcysteine (also referred to as N-acetylcysteine or NAC) is a known antidote delivered intravenously to treat an acetaminophen overdose. Between 2020 and 2022, ISMP Canada received two reports of acetylcysteine (NAC) infusion overdose incidents resulting in death, involving Canadian patients. After ISMP Canada was informed of additional incidents involving acetylcysteine infusions, ISMP Canada collaborated with HIROC to conduct an in-depth analysis of the reported cases and existing practices related to acetylcysteine infusions. HIROC provided expertise in human factors and patient safety towards the development of safety focused recommendations to reduce the risk of patient harm from acetylcysteine infusion errors. The recommendations were published in an ISMP Safety Bulletin in August 2023.
This presentation will outline the methods used for the analysis, which involved a review of reports submitted to ISMP Canada regarding acetylcysteine overdoses; a literature review regarding acetylcysteine overdoses; review of provincial poison centre protocols, examples of hospital order sets, and manufacturer and hospital monographs; interviews with healthcare providers and hospital safety specialists; and a site visit to a tertiary hospital to understand their local context (e.g., infusion pumps, order sets, and resources) for delivering acetylcysteine to patients.
The presentation will share the value of a human factors perspective during the analysis, as well as the key findings and recommendations. These recommendations align with recognized strategies for enhancing safety through risk mitigation, such as developing systems-focused interventions as demonstrated in the Hierarchy of Intervention Effectiveness. This includes the opportunity to standardize protocols and order sets across poison centres and hospitals or health regions; conduct end user testing of proposed protocols and order sets prior to implementation; ensure updated resources from poison centres are available and accessible by healthcare providers administering acetylcysteine; develop standardized order sets for administering acetylcysteine; centralize IV bag preparation by pharmacy; designate acetylcysteine as a high-alert medication in hospital drug libraries that offer safety alerts during pump programming; ensure separate drug libraries to differentiate between adult and pediatric patients; and administer loading doses from separate IV bags used for maintenance doses.
This presentation will outline the methods used for the analysis, which involved a review of reports submitted to ISMP Canada regarding acetylcysteine overdoses; a literature review regarding acetylcysteine overdoses; review of provincial poison centre protocols, examples of hospital order sets, and manufacturer and hospital monographs; interviews with healthcare providers and hospital safety specialists; and a site visit to a tertiary hospital to understand their local context (e.g., infusion pumps, order sets, and resources) for delivering acetylcysteine to patients.
The presentation will share the value of a human factors perspective during the analysis, as well as the key findings and recommendations. These recommendations align with recognized strategies for enhancing safety through risk mitigation, such as developing systems-focused interventions as demonstrated in the Hierarchy of Intervention Effectiveness. This includes the opportunity to standardize protocols and order sets across poison centres and hospitals or health regions; conduct end user testing of proposed protocols and order sets prior to implementation; ensure updated resources from poison centres are available and accessible by healthcare providers administering acetylcysteine; develop standardized order sets for administering acetylcysteine; centralize IV bag preparation by pharmacy; designate acetylcysteine as a high-alert medication in hospital drug libraries that offer safety alerts during pump programming; ensure separate drug libraries to differentiate between adult and pediatric patients; and administer loading doses from separate IV bags used for maintenance doses.
Authors
Senior Medication Safety Specialist
Event Type
Oral Presentations
TimeMonday, March 3111:15am - 11:37am EDT
LocationQueens Quay
Patient Safety and Research Initiatives (PS)