CASE STUDY

Reducing the Error Rate During IV Infusion

Lancaster General Health implements the Medi-Dose Line Tracing Labels to reduce
medication error rates and help create a standardization process.

Tina M. Suess, MHA, PRIMARY INTENDED OUTCOME(s)

BSN, RN – BC, CPHIMS
Manager of Medication Our goal was to reduce the error rate during IV infusion and create
Safety Integration
~ Lancaster General Hospital
standardization of line tracing protocol on infusion pumps by
implementing line tracing labels.
Amanda E. Prusch,
PharmD, BCPS
Clinical Pharmacy Specialist -
Medication Safety
~ P GY-1 Residency
Program Director

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CASE STUDY
THE CHALLENGE
As one of the first hospitals in the nation to integrate their smart pumps with EHR (Epic),
Lancaster General Hospital was using stickers, masking tape, and other variations to
handwrite and label IV lines and infusion pumps. Using more than 900 pumps (2-6 channels/
pump), this caused confusion, creating the need for LGH to reduce their error rate when
pushing and switching lines.
“Line trace itself is never something that technology is going to be able to do,” says Tina
Medi-Dose Line Tracing Labels Suess, Manager of Medication Safety for Lancaster General Hospital. “The technology cannot
make sure that the tubing is placed through the correct cassette or channel in the pump.”

THE DECISION
We determined that the Medi-Dose Line Tracing Labels would create ease-of-use for nurses
tracing lines on our high-risk medications:

“
• Heparin • Insulin
Medi-Dose turned • Oxytocin • TPN

something around
“
for us very quickly
“The line trace labels actually help us draw attention to an area in the process where
technology can exist, but we still need the human to do the right thing which is follow the
tubing from the bag through the pump to the patient,” Suess says.
to adopt.
After identifying a number of errors within their internal error report, Lancaster General
Amanda Prusch , Hospital realized with proper line trace, errors could be prevented.
PharmD, BCPS
Clinical Pharmacy Specialist -
Medication Safety
THE RESULTS
~PGY-1 Residency We established a line trace process, which began with the question, “how are we going to
Program Director label the line?” Lancaster General Hospital consulted Medi-Dose, where the two helped
establish a label standard concept.
At LGH, line trace needs to be done a minimum of every eight hours. Protocol dictates after
the nurse hangs the bag in the patient room, the label is placed on the bag, at the top of the
line, as well as the distal end of the line. The nurse’s hand should not leave the line during the
trace process, which allows for rapid identification of the correct line. Medi-Dose Line Tracing
Labels are flexible, offering color-coded or pre-printed customized options. Effectively, the
risk of misreading a label due to penmanship is eliminated.
Implementation of Medi-Dose 3-Part Piggy-Back Line Tracing Labels offer three important
benefits, including: facilitation of easy line trace, improved accuracy and minimization of IV
line confusion.

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CASE STUDY

“
 very hospital has
E
unique requirements.
In addition to the pre-printed High Alert Line Tracing Labels, Medi-Dose offers Customizable
Line Tracing Labels with its MILT software, allowing for such customization as:
• Bar Codes
• Graphics
Currently, our 100 • Special Fonts
• Colors
High Alert Tracing
• Tall-Man Lettering (TML)
Labels cover the most • Shapes and/or Logos
• Symbols and/or Pictures
common High Alert
“We can say that when we have taken that deep dive and really looked at all of our errors
medications. The related to heparin and adopted a couple different things, one was a line tracing process and
these [Medi-Dose line tracing] labels, overall our error rate definitely decreased,” said Amanda
new Customizable Prusch, Clinical Pharmacy Specialist - Medication Safety for Lancaster General Hospital.
Line Tracing Label Prusch continues, “after putting in several technologies, mostly manual-type processes, the
[Medi-Dose Line Tracing Labels] were part of the overall rate in dropping that number.”
extends line traces to
THE CONCLUSION
all IV and catheter Medi-Dose Line Tracing Labels is the tool that allowed Lancaster General Hospital to
lines. With MILT, standardize their line labeling process, according to Suess. While looking to drive consistent
workflow, the line label facilitates an easy-to-use fashion for the nurse.
on-demand printing “We’re very interdisciplinary here. The pharmacist facilitates those labels for nursing. The
nurse doesn’t have to go run someplace else to get the labels. So our approach that the
of labels can now
match each hospital’s
“ product actually gets dispensed with the bag when the nurse pulls it from Pyxis, is actually
saving the nurse a few footsteps and we always appreciate that,” said Suess.
Pharmacist oversight is now protocol for adjustments made by the nurse, including
exacting standards.
pharmacy validation and confirmation.
Robert Braverman
President “Line trace is something technology will never be able to do. Technology can’t make sure
~ Medi-Dose tubing is placed through the correct channel of a pump. [Medi-Dose] Line Tracing Labels
helped us draw attention to area where technology exists but we still need humans to
practice following the line from pump to bag to human,” Suess said.

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 1
Innovative
3-part
3 piggyback label
design. Just
peel & apply!

• Epidural
• Heparin
• Insulin

• Chemo

• Narcotic

• IV Nutrition
2 •
Oxytocin
• Paralytic

• Magnesium

Sulfate
• Intrathecal

• High Alert

• Blank

Visit our website to see our newest

stock additions…or easily customize
your own for any medication with
our exclusive MILT ® software.
Contact us for samples and more information.

EPS , INC. ®

Simplicity by Design...from EPS.

A Member of The Medi-Dose® Group.

Milton Building, 70 Industrial Drive

Ivyland, PA 18974 1 2 3
800-523-8966 Fax: 800-323-8966
215-396-8600 Fax: 215-396-6662
E-mail: [email protected] 3-part Line Tracing Label Line Tracing Label is easily Second Tracing Label
is placed on removed and placed at the is placed at the bottom
www.medidose.com infusion container. top of the line. of the line.