Smart Pumps and Drug Libraries The Way Forward

Similar documents
OHTAC Recommendation. Implementation and Use of Smart Medication Delivery Systems

One or More Errors in 67% of the IV Infusions: Insights from a Study of IV Medication Administration

To describe the process for the management of an infusion pump involved in an adverse event or close call.

Infusion device standardisation and the use of dose error reduction software: a UK survey

5th International Conference on Well-Being in the Information Society, WIS 2014, Turku, Finland, August 18-20, 2014

Intravenous Infusion Practices and Patient Safety: Insights from ECLIPSE

IV Interoperability: Smart Pump and BCMA Integration

IMPACT OF TECHNOLOGY ON MEDICATION SAFETY

Clinical. Medication Errors and Medicine Defect Reporting SOP. Document Control Summary. Contents

NATIONAL PATIENT SAFETY AGENCY DRAFT PATIENT SAFETY ALERT. Safer Use of Injectable Medicines In Near-Patient Areas

Alaris Products. Protecting patients at the point of care

In-Patient Medication Order Entry System - contribution of pharmacy informatics

To establish a consistent process for the activity of an independent double-check prior to medication administration, where appropriate.

Sharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use

Medicines Optimisation Patient Safety And Medication Safety. Dr David Cousins Associate Director Medication Safety and Medical Devices

SELF - ADMINISTRATION OF MEDICINES AND ADMINISTRATION OF MEDICINES SUPPORTED BY FAMILY/INFORMAL CARERS OF PATIENTS IN COMMUNITY NURSING

Management of Reported Medication Errors Policy

Organizational Overview

Achieving safety in medication management through barcoding technology

DERBY HOSPITALS NHS FOUNDATION TRUST PROJECT FINAL SUMMARY REPORT. Purchasing for Safety - Injectable Medicines

NHS Injectable Medicines Guide Project Outline

Improving the reporting of medication-related safety incidents

Improving Safety Practices Anticoagulation Therapy

Alaris Guardrails Quick Overview for Staff Pharmacists

Medication Error Incidents reporting survey. Consultation questions

Use of Intravenous devices for administration of fluid therapy in Neonates

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Injectable Medicines Policy

Reducing Medication Errors: National Update

Improving compliance with oral methotrexate guidelines. Action for the NHS

Recommendations from National Patient Safety Agency alerts that remain relevant to the Never Events list 2018

Clinical Skills Validation: Alaris Pump System

Introduction of EPMA in paediatric practice in UK:

Improving the Safe Use of Multiple IV Infusions

Supply and Use Midazolam 5mg/ml and 2mg/ml Injections

Safer use of anticoagulants: the NPSA patient safety alert Steve Chaplin MSc, MRPharmS

Reducing errors with epma electronic Prescribing and Medicines Administration. Stockport NHS Foundation Trust December 2013

Medication Safety Way Beyond the 5 Rights

Anatomy of a Fatal Medication Error

WHAT are medication errors?

National Medication Safety Network. Observatory Erskine David UKMI, Guy s and St Thomas NHS Foundation Trust

FIRST PATIENT SAFETY ALERT FROM NATIONAL PATIENT SAFETY AGENCY (NPSA) Preventing accidental overdose of intravenous potassium

Pharmacological Therapy Practice Guidance Note Medicine Reconciliation on Admission to Hospital for Adults in all Clinical Areas within NTW V02

Maryland Patient Safety Center s Annual MEDSAFE Conference: Taking Charge of Your Medication Safety Challenges November 3, 2011 The Conference Center

Running head: MEDICATION ERRORS 1. Medications Errors and Their Impact on Nurses. Kristi R. Rittenhouse. Kent State University College of Nursing

Moving the Green Medicines Bag from the Safety Agenda to QIPP

The Medicines Policy. Chapter 6: Standards of Practice. MISCELLANEOUS and DISCHARGE

Policy for the Administration of the First Dose of an Intravenous Antibiotic to Adult and Paediatric Patients by Nurses

Medication Safety Technology The Good, the Bad and the Unintended Consequences

Case Study from Parallon

Reconciliation of Medicines on Admission to Hospital

Alaris System. Medication safety system focused at the point of care

Alert. Patient safety alert. Promoting safer measurement and administration of liquid medicines via oral and other enteral routes.

Medication Safety Action Bundle Adverse Drug Events (ADE) All High-Risk Medication Safety

How to Report Medication Safety Incidents from a GP Practice on the National Reporting and Learning System (NRLS)

Social care guideline Published: 14 March 2014 nice.org.uk/guidance/sc1

Plum 360 TM Infusion System with Full IV-EHR Interoperability

Disclosure statement

PURPOSE To establish a standardized process for the activity of an independent double check for medication administration.

Pharmaceutical Services Report to Joint Conference Committee September 2010

Infusion Pumps: a structured approach to drug library optimization

Optimizing Patient Outcomes

Preventing Adverse Drug Events and Harm

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST. Parenteral Concentrated Potassium and Sodium Policy

Managing medicines in care homes

Safermeds Survey Report

AUTOMATION TO IMPROVE THE SAFETY AND THE EFFICIENCY OF DRUG MANAGEMENT

Designing a System to Reduce Infusion Pump Errors

Nationally Recognised Framework for Accreditation of Pre and In-Process Checking within Aseptic Services

W e were aware that optimising medication management

Safe Medication Practices

Clinical Check of Prescriptions in Ward Areas

Contributing to a culture of safety by increasing usage of the drug library on smart infusion pumps: A Quality Improvement Project

Considerations for Sterile Compounding of Parenteral Products for Pediatric Use: Part 2 PharMEDium Lunch and Learn Series LUNCH AND LEARN

Session Objectives. Medication Errors in Adults and Children. Dennis Quaid American Society of Health- System Pharmacists (ASHP) Meeting December 2009

Nationally Recognised Framework for Pre and In Process Checking Accreditation within Aseptic Services

Session 2 Improving Narcotics and Opiate Management

Medication Safety & Electrolyte Administration. Objectives. High Alert Medications. *Med Safety Electrolyte Administration

Prescription Writer/ eprescribe

To provide protocol for medication and solution labeling to ensure safe medication administration. Unofficial Copy

Data Entry onto the National Immunoglobulin Database

Executive Summary points to consider by organisations providing Primary and Community Health services

McKinley T34 Ambulatory syringe pump Used in the provision of adult palliative and end of life care

UKMi and Medicines Optimisation in England A Consultation

UNDERSTANDING THE CONTENT OUTLINE/CLASSIFICATION SYSTEM

IV-EHR Interoperability

Reducing Medical Errors at the Bedside

End-to-end infusion safety. Safely manage infusions from order to administration

To prevent harm to patients from adverse medication events involving high-alert medications.

Medication Errors in Chemotherapy PORSCHA L. JOHNSON, PHARM.D. CLINICAL PHARMACIST II MEDSTAR WASHINGTON HOSPITAL CENTER SATURDAY, SEPTEMBER 17, 2016

I ntravenous (IV) medication errors have led to considerable

FRAMEWORK BRIEF. Parenteral Nutrition

Kate Beaumont. Strategy Advisor, NPSA Head of Clinical Interventions, National Patient Safety Campaign.

Human Factors and Ergonomics in Health Care and Patient Safety

TECHNICAL PHARMACY CURRICULUM GUIDE 2011/12

Constant Pursuit of Medication Safety. Geraldine Koh Chief Pharmacist

Introducing ISMP s New Targeted Best Practices for

NHS Lanarkshire Policy for the Availability of Unlicensed Medicines

POLICY FOR ANTICIPATORY PRESCRIBING FOR PATIENTS WITH A TERMINAL ILLNESS Just in Case

ANTIBIOTIC ADMINISTRATION & MEDICATION ERROR AND REPORTING 12 th APRIL 2010

Guidance notes on National Reporting and Learning System official statistics publications

Transcription:

Smart Pumps and Drug Libraries The Way Forward Kathryn Phillips North West Regional MI Centre The first stop for professional medicines advice

Outline The drivers behind the development/use of Smart Pumps What are Smart Pumps & Drug Libraries Where does MI fit in?

Where Medication Errors Occur Start of infusion (NPSA 05/06 59%) 138,117 Medication errors were reported to NHS NRLS in one year (April 12-March 13) Medication errors at administration stage account for: 34% of adverse events (Bates et al 1995) 38% of adverse events (Kohn 1999, Rodriguez, 2011) 42% of adverse events (NPSA 2010) * NHS NRLS used to be NPSA

MHRA Patient Safety Alert 20 March 2014 Patient Safety Alert Stage Three: Directive Improving medication error incident reporting and learning Sign up to Safety Campaign Launched by Health Secretary 20 March 2014 Aim to half avoidable harm in the next 3 years and save 6000 lives. Trusts which take action to reduce harm and claims => One off reduction in clinical negligence insurance premiums

What are SMART Pumps? Smart Infusion pumps can help prevent medication errors by alerting you to a pump setting that doesn't match your drug administration guidelines Drug Libraries convert a conventional IV pump into a Smart Pump Smart Pumps can log data e.g. time, date, drug, concentration, rate, volume infused, near misses allows audit, education and improvement

Braun Infusomat Space for infusion bags Braun Perfusor Space for syringes

Drug Libraries Let nurses and clinicians select medication and fluids from pre-set lists Each drug library can be tailored to specific care units Southport General Wards ICU Obs & Gynae Leeds General Wards ICU Obs & Gynae Can set hard and soft limits Hard will not let infusion proceed Soft will notify clinician/nurse and ask if they want to override and proceed A & E

Barriers to DERS / Smart Pumps? Smart pumps have been widely available in the UK since 2005 Most UK hospitals already have Smart Pumps but don t utilise the technology Historical Barriers Creation of Drug Library Creating the initial drug library is a significant amount of work for the hospital usually pharmacy Logistics Before WiFi, uploading of the drug library and any changes to it would have to be carried out manually. All pumps in a hospital had to be physically located and returned to the Medical Equipment Library

Learning Points Need to be involved in the decision making process, tender and implementation Dedicated Project Team link to Trust Board Level More time consuming than we thought! Need IT involved at the start More discussion with Medical Equipment Library How many pumps available? Which drugs to target initially? Segregation between wards? WiFi

Real Data Data courtesy Graham Cox Leeds Teaching Hospitals NHS Trust

Ward Data Data courtesy Graham Cox Leeds Teaching Hospitals NHS Trust

Ward Data Data courtesy Graham Cox Leeds Teaching Hospitals NHS Trust

Where does MI fit in? The Tendering Process Needs a dedicated pharmacist to be involved from the start Risk Minimisation The Drug Library An MI pharmacist has the skills to ensure there is a clear safe strategy for introduction of the pumps Writing The MI pharmacist has all the reference sources at their fingertips for writing the drug library but will need to liaise with clinical specialists QA MI pharmacists are excellent at QA

The Process and MI Education & Training Ongoing updates Project Board Lead A pharmacist needs to be involved both with pump training, explaining the benefits of the drug library, and with the clinical information that has been programmed Information from drug alerts, company information, discussion groups etc comes to the MI Pharmacists Reports on drug library progress: usage, changes required, incidents prevented, resulting education Communication at the start and throughout the process Succession planning Collaboration (Carter)

What can go wrong Staff not using the drug Library Overriding soft limits Infusion related errors may still occur Incorrect drug chosen from the drug library Right drug given to the wrong patient Drug already given and given again Infusion is within maximum limits but is incorrect for the patient

Future Possibilities A Bar-Code Medication Administration System is needed (BCMA) Would ensure right patient gets the correct drug, dose, route at the right time All infusions given via SMART Pumps

2024 © careersdocbox.com Privacy Policy | Terms of Service | Feedback