Utilizing QI Tools to Decrease Line Contaminiations

A trend of nursing errors has been identified in our Bone Marrow Transplant (BMT) patients in whom central lines were contaminated by incorrect administration of tacrolimus or cyclosporine. These drugs have the potential for significant drug absorption when given through plastic administration tubing. Once the drug has been administered through a central venous catheter (CVC) lumen, drug monitoring levels cannot be obtained through that lumen due to risk for falsely high levels. When initiating IV tacrolimus or cyclosporine therapy, the nurse is responsible for identifying which lumen will be utilized for drug administration and which lumen will be utilized for drug level monitoring. If the drug is inadvertently administered in all available lumens, drug level monitoring must be obtained peripherally.    

These nursing errors resulted in significant patient harm, as patients required painful venipuncture procedures for ongoing drug level monitoring, rather than comparatively painless lab draws through a CVC. A review of the event reporting system identified 5 patients who were harmed by incorrect administration of tacrolimus or cyclosporine between 01/01/1211 and 3/31/12. This baseline data revealed a rate of 0.24 line contaminations per 100 IV doses of tacrolimus or cyclosporine administered (0.24/100). All of these errors were the result of contamination of the central venous catheter due to administering drug through all available lumens, rather than identifying a single lumen for administration and another single lumen for drug level monitoring.

                In response to this trend, a team was developed to plan and implement a Quality Improvement (QI) project addressing the process for administration and drug monitoring for patients receiving these drugs by implementing the Institute for Healthcare Improvement (IHI) model for QI. The IHI model utilizes the Plan-Do-Study-Act process in which a series of small tests of change are implanted to achieve desired results. The team established the standard nursing practice as administration of tacrolimus or cyclosporine through the white lumen of the tunneled CVC and lab draws for drug monitoring through the red lumen of the tunneled CVC. BMT nurses were informed of the new standard practice during twice daily safety huddles. Nurses were instructed to remember the standard as “red for blood” meaning to draw from the red lumen. Since implantation of this standard practice there have been zero reported line contaminations.