Newborn and Infant Nursing Reviews
Volume 6, Issue 4 , Pages 230-236 , December 2006

Nix the Six: Raise the Bar on Medication Delivery

  • Anne Swanson, MSN, RNC

      Affiliations

    • Corresponding Author InformationAddress correspondence to Anne Swanson, MSN, RNC, Neonatal Clinical Nurse Specialist, Director of Clinical Services, Smiths Medical, 2231 Rutherford Road, Carlsbad, CA 92008.

References 

  1. In:  Kohn LT,  Corrigan JM,  Donaldson MS editor. To err is human: building a safer health system. Washington (DC): National Academy Press; 1999;
  2. Niemi K, Geary S, Larrabee M, et al. Standardized vasoactive medications: a unified system for every patient, everywhere. Hosp Pharm. 2005;40:984–993
  3. Kaushal R, Jaggi T, Walsh K, Fortescue E, Bates D. Pediatric medication errors: what do we know? What gaps remain?. Ambul Pediatr. 2004;4:73–81
  4. U.S. Pharmacopeia . Understanding and preventing medication errors: a resource for practitioners. Medmarx Reports for 2001 and 2002. CD ROM available at www.usp.org/patientsafety2004;
  5. Grissinger M. “Rule of 6” not optimal for patient safety. P&T. 2003;28:234
  6. Veltri MA, Ascenzi J, Clark J, et al. Why didn't I think of that…? Standardizing medication ordering, dispensing, and administration systems to eliminate the “Rule of Six”. PP&P. 2006;1:30–32Retrieved June 1, 2006 from http://www.pppmag.com/documents/PPP_V3N2_pp32-33_Ruleof6.pdf
  7. Joint Commission on Accreditation of Healthcare Organizations. National Patient Safety Goals for 2005 and 2004. Retrieved September 11, 2004 from http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm.
  8. Rich D. More on the requirements of the medication-related national patient safety goals for 2003-2004. Hosp Pharm. 2003;38:977–989
  9. U.S. Pharmacopeia. Patient Safety: CAPSLink. June 2004. www.usp.org/patientsafety.
  10. Pharmacopeia Form. July- Aug. 2003. 29. Retrieved June 6, 2006 from http://www.mic4.com/regulations/USP-797.pdf.
  11. University of Virginia: Rule of Six vs standardized drips. Retrieved July 7, 2002 from ICUdrips website at the University of Maryland (www.icudrips.org).
  12. Institute for Safe Medication Practices, ISMP Medication Safety Alerts. Vol 4; Vol 8; 4; Vol 5; Vol 8]. Retrieved May 20, 2006 at: http://www.ismp.org/MSAarticles/recentarticles.html.
  13. Stucky ER. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112:431–436
  14. Mitchell A, Sommo P, Mocerine T, et al. A standardized approach to pediatric parenteral medication delivery. Hosp Pharm. 2004;39:433–459
  15. Levine S, Cohen M, Blanchard N, et al. Guidelines for preventing medication errors in pediatrics. J Pediatr Pharmacol Ther. 2001;6:426–442
  16. Gaffoor M, Vaidya V. Rule of Six versus standardized drips: the ongoing debate. AAP Section on Critical Care. Newsletter. 2004;6–7
  17. Joint Commission on Accreditation of Healthcare Organizations. 2006 National Patient Safety Goals FAQs. Retrieved June 1, 2006 from http://www.jointcommission.org/NR/rdonlyres/36E5AAAA-5FDB-47FA-85C7-E66191AB918C/0/06_npsg_faq3.pdf.)
  18. Kastango ES. Bradshaw BDL USP chapter <797>: establishing a practice standard for compounding sterile preparations in the pharmacy. Am J Health Syst Pharm. 2004;61:1928–1938
  19. Larsen GY, Parker HB, Cash J, et al. Standard drug concentrations and Smart-Pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;116:21–25

PII: S1527-3369(06)00100-0

doi: 10.1053/j.nainr.2006.09.003

Newborn and Infant Nursing Reviews
Volume 6, Issue 4 , Pages 230-236 , December 2006