Mr. McAllister is a health-systems consultant based in Chapel Hill, North Carolina.
Several excellent educational sessions related to intravenous (IV) therapy were featured at the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in December, prompting me to reflect upon how much more diverse, sophisticated, and complicated IV therapy has become during my career.
The IV route is used much more frequently now than it was 20 years ago, with virtually every hospitalized patient receiving IV therapy at some point during his or her admission. Similarly, the IV route is increasingly used in the ambulatory care environment and in diagnostic and procedure labs. I am troubled, however, that pharmacy departments consider IV solutions that have not been compounded in their pharmacy to be products for which they are not responsible.
Medical and technological advances, as well as market forces, have contributed to the evolution of IV therapy. IV chemotherapy, which has become much more sophisticated, is routinely administered in ambulatory care environments. New IV packaging extends well beyond a limited number of intermittently administered antibiotics to include a broad array of base solutions with electrolytes and other additives.
Certain intravenously administered drugs are available exclusively through specialty pharmacy distributors over which pharmacy departments have little or no control. Intelligent infusion devices, which have been shown to reduce dosing errors associated with IV infusions, include drug libraries with minimum/maximum dose-checking functionality and monitoring capabilities using wireless technology. Hospitals and their departments of pharmacy have invested heavily in technologies that are intended to improve various facets of the medication use process. Given these advancements, it is understandable that pharmacy departments have prioritized their resources to maximize quality, efficiency, and cost-effectiveness. Distribution of IV base solutions is often relegated to materials management or a similar department, and routine monitoring of use is reserved only for those patients who have fluid and electrolyte challenges.
As a result, we largely ignore IV solutions without additives as a commodity for which we have little responsibility. In some hospitals, pharmacy departments have allowed IV solutions with premixed electrolytes to be issued by other departments or purchased on standing purchase requisitions by procedure labs and other departments; administration is at their discretion, without oversight.
All IV drugs and solutions are deemed legend drugs for good reason, not only by the FDA but also by the Joint Commission on the Accreditation of Healthcare Organizations and ASHP in their standards and guidelines. The IV route of administration is implicated in far too many serious medication errors. I suspect that the underreporting phenomenon is prevalent with this group of drugs and the diverse environments in which they are used.
It is time for pharmacy to assume responsibility for all IV therapy in all environments. This does not mean that all IV fluids must be dispensed by the pharmacy department.We must design and implement system safeguards, however, to ensure that these drugs are administered safely and appropriately. IV solutions are medicines; they are not commodities. We must not let the trend of seeing them as such continue or proliferate. What do you think?
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