Working the SMART way

The NPSA 20 alert ‘Promoting Safer Use of Injectable Medicines’¹ highlighted the high level of patient safety incidents associated with injectable medicine administration in the NHS. There were 14,000 incidents with intravenous (IV) medicines reported to the NPSA between January 2005 and June 2006. Of these, 3000 caused harm and 25 resulted in death. 59% of these errors occurred during administration. There has been some improvement but there were still 138,117 medication errors reported to NHS NRLS (was NPSA) between April 12 and March 13 of which 38% were at the point of administration.²

The Medicines and Healthcare products Regulatory Agency (MHRA) has seen a sizeable increase in reports of identifiable morbidity and mortality involving infusion devices (volumetric pumps and syringe drivers) during the last decade as their use has grown exponentially.

The MHRA Patient Safety Alert March 2014 Stage three: Directive – Improving medication error incident reporting and learning,³ would be facilitated by the use of SMART pumps as they can log and track all alerts, recording the time, date, drug, concentration, and infusion rate, as well as whether an alert has been overwritten or the pump has been reprogrammed with different settings. This information can be used for learning and to shape current practice guidelines.

The ‘Sign up to Safety’ campaign⁴ recommended that NHS Trusts should draw up plans to halve ‘avoidable harm’ such as medication errors, blood clots and bed sores by 2016–2017 and Trusts which ‘take action’ will benefit from a reduction in their NHSLA premiums. Smart Pumps are definitely one way of ‘taking action’.

Despite ‘drug error reduction software’ (DERS) being available in the UK since 2005,⁵ and NPSA 20¹ recommending dose checking software in ‘smart’ infusion pumps, many Acute Trusts do not appear to have installed or use this software on their infusion devices. Some Acute Trusts have incorporated elements of DERS on critical care units, for example, displaying drug infusion name on the liquid crystal displays, but not on general wards. NPSA 20 highlighted that ‘smart’ infusion pumps incorporating dose-checking software can cost up to £1000 more than other pumps but encouraged organisations to consider the benefit of the additional features when planning pump replacement programmes.¹

A SMART pump is basically a pump which can be programmed so that it will alert a nurse or doctor to an infusion rate/dose/concentration which is outside of a particular medication’s recommended parameters. Drug administration guidelines are entered onto a database and form the drug library. The drug library is uploaded onto a pump to convert it into a SMART pump.

Drug libraries let doctors and nurses select medications and fluids from pre-set lists, which can be tailored to each hospital and patient care area. For example, a drug library profile used in an ICU would include vasoactive medications; one in a medical-surgical unit probably would not. In our Trust we decided to have three care units: Critical Care, General Wards and Obstetrics and Gynaecology. Drug libraries include hard and soft limits, on preselected drugs.

If a user programs a SMART pump outside predetermined dose or rate parameters for a drug with hard limits, the pump generates an alert and won’t let the selection proceed. With soft limits, the alert can be overwritten (following appropriate checks) and the infusion can proceed. These soft limits are often used on critical care medication.

The SMART pump’s software can log and track all alerts, recording the time, date, drug, concentration, and infusion rate, as well as whether an alert has been overwritten or the pump has been reprogrammed with different settings. This information can be used to shape current practice guidelines. For example, if a particular medication or dose is frequently overwritten, investigation may find that staff have been frustrated with too restrictive limits so the drug library parameters for that drug may need to be changed. Conversely, these same alerts may also highlight a need for further education about acceptable dosing in specific patient populations, or in specific patient care areas.⁶

Southport and Ormskirk NHS Acute Trust supported the use of six different makes/models of volumetric pump and three different makes/models of syringe driver. Such a range of infusion devices was due to an historical lack of cohesive purchasing policy throughout the Acute Trust and many devices were over 10 years of age. This diversity caused much confusion amongst staff and anecdotally, gave rise to a number of ‘near miss’ incidents as training staff on such a varied range of infusion devices proved unworkable.

In order to reduce such risks, both the MHRA⁷ and National Patient Safety Agency (NPSA)⁸ advocate rationalising makes and models of infusion devices within an Acute Trust.

Following a trial of B Braun and Carefusion Alaris infusion pumps on a Critical Care Unit, a surgical ward and a general ward, B Braun ‘SMART’ infusion pumps were purchased.

The Medicines Information Pharmacist and the Intensive Care Pharmacist started working with a Clinical Product Specialist from Braun to write and populate a drug library incorporating the use of drug error reduction software. Unfortunately due to time constraints (both pharmacists part time with other work commitments) and initial software problems this was a very lengthy process. A basic General Ward Drug Library was written using our in-house intravenous drug administration guidelines and uploaded onto the pumps.

This in itself was a timely process as all pumps had to return to the medical equipment library for this to be uploaded as no Wi-Fi was available. The initial plan had been to write a drug library which contained three care units: Critical Care, General Ward and Obstetrics and Gynaecology.

Eleven pumps were randomly chosen throughout the hospital and their data downloaded manually (Table 1) as we did not have a Wi-Fi connection. Unfortunately, because of this the origin of the data (that is, which ward the pump came from) was not available.

The drug library was only being used 24% of the time! (Unfortunately, there has to be an option to bypass the drug library, as all drugs will not be available via the library). However, even with this low level of drug library usage 15 drug-related errors were prevented, three of which were for insulin.

Figure 1: Hard limit breaches. NB. Five were when the maximum rate of the pumps had been breached

Figure 2: Which drugs are given using the drug library?

These results highlighted how the use of SMART pumps can prevent serious errors with intravenous medication but education and further training of nursing staff is urgently needed.

The results were presented to the Director of Nursing and at a senior nurse management meeting and the Medicines Information Pharmacist was given a three-week secondment to complete the full drug library which included three care units: Critical Care, General Wards and Obstetrics and Gynaecology.

The Critical Care care unit contains all standard medication but also higher concentrations, minimum infusion volumes and vasoactive medication. The Obstetrics and Gynaecology care unit has a reduced list of medication but also hydralazine and different magnesium and labetalol infusions for pre-eclampsia.

Full Wi-Fi connectivity will be available around June 2016. Continued use of the SMART pumps without Wi-Fi connectivity would be a risk in itself, as any necessary changes to the drug library would take a long time to upload onto all pumps and it would be difficult to identify which pumps had the most up to date drug library installed.

An initial trial will take place on the Critical Care Unit when any issues can be detected and ratified. Once all areas have completed their training, all the care units will be rolled out across the trust. A follow up review of the SMART pump and drug library usage will take place at the end of the year.

• SMART pumps can prevent serious errors with intravenous medication.
• Thorough education and training of medical and nursing staff is essential.
• Time should be allocated to pharmacy staff to complete the drug libraries
• Wi-Fi connectivity should be available to allow timely upload of any changes to the drug libraries.

1. UK National Patient Safety Agency. Patient Safety Alert 20: Promoting Safer Use of Injectable Medicines. London:NPSA;2007.
2. National Reporting and Learning System (NRLS) national database of patient safety incident reports.
3. Patient Safety Alert Stage three: Directive – Improving medication error incident reporting and learning. March 2014. MHRA and NHS England.
4. Sign up to Safety, National Patient Safety Campaign. June 2014. NHS England.
5. B Braun website.
6. NHS Purchasing and Supply Agency. Buyer’s Guide: Dose error reduction systems for infusion pumps. September 2008.
7. Medicines and Healthcare products Regulatory Agency. Infusion Systems, December 2013
8. UK National Patient Safety Agency. Safer Practice Notice: Improving infusion device safety. London:NPSA;2004.