Designing a System to Reduce Infusion Pump Errors Robert Bruce, MA, MPA Senior Manager, Contracts South East LHIN Daphne Broadhurst, BScN, RN, CVAA(C) Clinical Specialist OMS/Medical Pharmacies South East Community Care Access Centre 1
Technology is the blessing at our disposal but still a potential curse in our execution. https://www.linkedin.com/pulse/how-technology-has-become-blessing-curse-paulhollington
7,000 patients per year die from medication errors IV infusions have been identified as the most frequent contributors to administration errors (Husch et al., 2005) 73% probability of making at least 1 error infusing intravenous therapy (McDowell et al, 2010)
Smart Pump Technology - Why? CADD-Prizm pump discontinued
Why a Smart Pump? Designed to recognize: Prescription errors Dose misinterpretations Keypad errors Dose Error Reduction Software (DERS) Drug protocol library Decision support Safety checks/alerts Reports for continuous quality improvement (CQI)
Infusion pumps have contributed to improvements in patient care, allowing for a greater level of control, accuracy, and precision in drug delivery, and thereby reducing medication errors. At the same time, like other medical devices, infusion pumps are not without risks. 6
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PCA, compared to other types of medication errors, represented a fourfold higher relative risk of harm (Hicks et al., 2008)
What Errors are occurring? 1. Wrong concentration 2. Wrong dose 3. Wrong time 4. Pump not started 5. Wrong medication Unpublished data
Project Goals Gain a shared understanding among LHIN, nursing providers and infusion vendor on patient safety events related to errors in programming infusion pumps Gather information on infusion pump practices and education and identify areas for improvement Implement preventative measures Reassess residual risks 12
13 Contributing Factors
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Service Provider Contract Letter Use of a Contract Letter as a formal mechanism to define the expectations of the LHIN in meeting defined service requirements as follows: 15
Use of a Standard Pump Documentation Form The Service Provider shall adopt use of the CADD Solis PCA Infusion Record and the CADD Solis Intermittent Infusion Record and shall provide ongoing training of its nurses on the correct use of the Record based upon the accompanying document: Guidelines for Completion of the CADD Solis PCA/CADD Solis Intermittent Infusion. 16
Adoption of an Independent Double Check process The South East had adopted the Institute for Safe Medical Practices (ISMP) statement on independent double checks This statement to be adopted by all nursing Service Providers in the South East as a minimum requirement in each Service Provider developing its own Policy and Procedure. The South East will request proof of each Service Provider P&P and how the Service Provider will educate staff on and monitor the effectiveness of the P&P. 17
Processes to identify and cope with distractions in the environment The key concept in dealing with distractions is to (a) identify and (b) create management strategies to mitigate the impact of distractions in the home. As part of the Service Provider P&Ps, strategies to cope with distractions are to be included and at a minimum should consist of the following set of strategies: Find a quiet spot such as a bathroom, away from the distractions to prepare medications and complete calculations Set clear expectations with the patient and family ahead of time when the nurse must concentrate uninterrupted on a specific task Turn off the television, radio during a specific task Nurse taking a time out in her car to refocus Have clear expectations of what assessments and care is required at the specific visit and confirm that the care is complete 18
Communication between the Service Provider and its nurse upon a new/change in orders The Service Provider shall adopt a process whereby all new or change IV orders are provided in writing to each nurse providing IV care. 19
Service Provider Staff Training Expectations Each Service Provider shall train its nurses on use of the Record and standards of the LHIN Contract Letter (upon new hire and annually as a refresher at a minimum). Training shall: 20 Include the background for the project and contributing factors/rationale Address the following topics: pump protocol and concentration not changed checking medication with pump settings, the written order and the cassette independent double check distractions in the environment calculating the amount of medication remaining nursing assessment at each visit: verifying medication cassette with pump settings at each visit symptoms (pain, LOC, N&V) Define expectations for completion of the Record and required Infusion practices P&Ps
LHIN expectations of the Service Provider and Monitoring The South East LHIN expects that each Service Provider shall: Develop or review existing internal P&Ps for Infusion practices; Create an audit plan Conduct annual refreshers of Record and internal P&Ps Review their Infusion P&Ps with each nursing staff member The Service Provider shall conduct an audit of 20% of IV patients per month Continue to work actively with the South East LHIN to increase the 21 safety of infusion therapy
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23 Pump Programming Errors Pre and Post Project Implementation
Safety Strategies
While we would like to believe otherwise, technology is not perfect, expect errors or have a plan B Lt Gen Ted F. Bowles, Commander 26