Director of Pharmacy
Coordinator of Drug Use Policy
Clarian Health Partners Pharmacy Department
In 1999, the US Institute of Medicine (IOM) published its widely reviewed report To err is human: building a safer health system. This report gained much attention with its claim that 98,000 deaths occurred in US hospitals each year due to medical errors, with nearly 7,000 of the deaths being related to medication errors.(1) Although this has been debated, the IOM report spurred hospitals to re-evaluate their processes in the prescribing, preparation, delivery and administration of medications. Hospitals have increased their focus in adopting technology to prevent adverse drug events that lead to patient harm. Information technologies that have been implemented include computerised physician order entry, automated drug dispensing cabinets and barcode patient verification for medication administration. However, these technologies do not directly address the errors associated with the errant programming of intravenous (IV) infusion devices. IV drug errors represent a category of errors that can lead to very serious patient injury. These drugs are often given to critically ill patients, and the result of an error in their administration can have a negative impact on patient outcome. This article discusses a new decision-support technology that can avert IV medication errors resulting from improper programming of infusion devices.
Bates et al described the medication use process as four phases:(2)
- Prescribing by physicians.
- Transcription of the order.
- Dispensing of the medication.
- Administration of the medication to the patient.
In examining the source of actual or potential medication errors, it was found that 49% occurred in the prescribing phase, 11% in the transcription phase, 14% in the dispensing phase and 26% in the administration phase. Of note, a significant percentage of potential errors were intercepted before reaching the patient when they occurred in the prescribing, transcription and dispensing phases of the process. However, no errors that occurred during the administration phase of the medication use process were averted before reaching the patient.(2) The challenge for hospitals addressing medication safety is to adopt technologies that provide intelligent decision-support software at the time of medication administration in order to prevent these errors. A recently introduced infusion technology often referred to as “smart pumps” provides this support, with a safety check at the bedside to promote the safe administration of IV solutions.
Traditional IV infusion devices are multipurpose and can be utilised for the infusion of a variety of products, ranging from standard IV solutions to complex total parenteral nutrition solutions. These pumps have a wide range of infusion capabilities and can accurately infuse solutions at rates as low as 0.1ml/h for the neonatal intensive care patient to 999ml/h for bolus dosing of adult patients in emergency care situations. One safety concern with these pumps is their lack of ability to evaluate the programmed dose for accuracy when administering medications or solutions. For example, an infusion rate intended for a 500g premature infant could be misprogrammed at a rate that would be more appropriate for a 150kg adult. Traditional infusion devices contain no dosing or infusion guidelines that would alert the user of this potentially fatal error.
The introduction of “smart” infusion pumps (see Figure 1) represents a significant advance in patient safety systems, by providing an automated dosing safety check at the time of administration of IV solutions and medications. These devices have clinical decision-support software that allows doses and infusion rates to be checked versus dosage parameters defined by the institution. Typically, minimum and maximum doses and rates for commonly infused solutions are preprogrammed in the infusion pumps. If the user programmes a dose or rate that is either above the maximum or below the minimum dose/rate, the device will produce an alert that a potentially errant dose or infusion rate has been entered. The alert prompts the user to reprogramme the device to a dose that is within the defined limits. This decision-support alert system has been shown to prevent numerous programming errors, potentially significant medication errors and patient harm. Smart pump dosing guidelines can be defined for distinct patient populations, as most hospitals develop institution-specific dosing schedules for their diverse patient groups. In addition to dosing alerts, smart infusion pumps have the capability to link drug information notes to specific medications programmed into the pump’s drug library. These notes provide small but helpful bits of information to the user that can avert a potential medication error. For example, the co‑infusion of an IV solution containing calcium with a solution containing phosphate can cause a precipitate and consequently result in thrombosis for the patient. With smart pumps, the user, when starting a calcium infusion, would receive an alert stating: “Do not infuse with a phosphate solution.” This simple alert can avert serious patient medication error.
Smart infusion pump technology includes the ability to store and download each alert and reprogramming event. Recently published studies have examined the effect of smart pumps in relation to the quantity of alerts and reprogramming events recorded by the pump. A significant number of potentially harmful errors in IV medication were prevented via the use of the smart pump technology.(3–5)
Additional applications of smart pump infusion technology and its clinical decision support capabilities have included its use in syringe infusion and patient-controlled analgesia (PCA) devices. In the future, smart pump infusion technology may be linked with other clinical databases (eg, laboratory). This integration of clinical support systems will further enhance the safety net of the entire medication delivery system and ensure that patients receive the appropriate infusion rate and dose of medication, and avoid potential errors at the time of administration.
Smart infusion pump technology has been shown to decrease the number of potentially harmful errors during the administration phase of the medication use process. It provides a safety net for programming the dose and rate of the medication to be administered. In addition, it provides important dosing reminders to the user.
This infusion pump technology should be considered when reviewing information technologies to improve medication safety and the administration of appropriate IV medications and solutions.
- Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Institute of Medicine. Washington, DC: National Academy Press; 1999.
- Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;272:35-43.
- Malashock CM, Shull SS, Gould DA. Effect of smart infusion pumps on medication errors related to infusion device programming. Hosp Pharm 2004;39:460-9.
- Maddox RR. Using IV medication safety system logs-a new tool for identifying averted harm. Infusion Safety Conference, November 7, 2003, San Diego, CA, USA (poster).
- Crass R. Potential for harm in IV system programming: a 10-hospital analysis. Infusion Safety Conference, November 7, 2003; San Diego, CA (poster).