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Successful Elimination of the “Rule of Six” in an Academic Children’s Hospital Through a Medication-Use-System Redesign and Standardization of Continuous Infusions

Michael A. Veltri, Pharm.D., Judith Ascenzi, R.N., M.S.N., John S. Clark, Pharm.D., M.S.,  Mary W.Taylor, R.N.,, M.S., Carol Matlin, R.N., M.S., Timothy R. Ulbrich, Christoph U. Lehmann, M.D.


The Johns Hopkins Children’s Center, Baltimore, Maryland

With goals of reducing continuous infusion medication errors and safely transitioning this 180 bed academic children’s center from nonstandardized concentration (Rule-of-Six) to standardized concentration continuous infusions (SC), a 2½-year, multidisciplinary project addressing order errors and redesigning the medication-use-system was completed.

The program evolved in stages, beginning with an error rate assessment of handwritten continuous infusion orders completed during the months of February and March 2003.  Next, a web-based application (Harriet Lane Infusion Calculator© {HLIC} version 1) was developed on-site.  This computerized the ordering of continuous infusion medications, automating the Rule-of-Six to provide legible, computer-generated paper orders (demo-  Post-implementation the order error rate was reassessed with a second data collection.  A significant reduction in prescriber errors was demonstrated with the introduction of the HLIC.  Once the HLIC program proved beneficial its use in the Children’s Hospital was mandated for continuous infusion orders. 

The second phase consisted of the development and implementation of SC.  Considerations included (1) usual doses and corresponding infusion rates for all weights, (2) drug stability, (3) commercially available “pre-mixed” products, and (4) stock drug concentrations/vial sizes.  SC were developed for 51 drugs and integrated into the HLIC’s second version with default starting doses, dosing limits, administration warnings, and drug specific diluent choices (demo-  Additional supportive functionality was added to the HLIC version 2, including a link to the hospital patient census database (to reduce key stroke errors) and patient and infusion concentration specific parameters necessary to aid prescribers in the choice of appropriate SC (i.e., flow rates needed for an ordered dose for each specific SC in mL/hour, mL/kg/day, and percent of calculated daily maintenance fluid).

For all SC developed, matching pre-built choices were incorporated into the pharmacy computer system to standardize compounding and labeling, ease order entry, and reduce the likelihood of entry error.  This also eliminated the need for any calculations by the pharmacist at the point of order entry.  In parallel, syringe pumps were purchased, having “smart pump” capability.  Medication libraries were developed to match the SC items, with dosage limits, automated rate calculations, and administration and other warnings. 

Continuous infusion order error rates decreased significantly with the implementation of the HLIC version 1, reducing the 27% error rate for handwritten orders to 6% (78% reduction, p<0.01).  After implementation of SC and the HLIC version 2, continuous infusion order error rates were further reduced to 2% (a 67% error rate reduction compared to HLIC Version 1, p=0.032 and a 93% rate reduction compared to handwritten orders). Since its implementation in February 2005, more than 3200 infusions have been ordered and administered using this system.  Problems have been few and resolvable. The last step will be integration into the Computerized Provider Order Entry (CPOE) system, which is scheduled for early 2007.

Elimination of the “Rule of Six” continuous infusions and reduction of continuous infusion medication errors can be safely achieved in an academic pediatric medical center, however a complete medication system revision (ordering, dispensing, and administration) andmultidisciplinary support are required.

View a pdf of the poster from the Midyear Meeting (1.3MB).