Preventing harm from risky meds: Role of smart pumps

February 7, 2005

Smart infusion pumps have helped reduce medication errors at many facilities. But cultural changes are needed in hospitals to improve results, according to a panel of pharmacy executives who spoke at ASHP's Midyear Clinical Meeting in Orlando, Fla., in early December.

Smart infusion pumps have helped reduce medication errors at many facilities. But cultural changes are needed in hospitals to improve results, according to a panel of pharmacy executives who spoke at ASHP's Midyear Clinical Meeting in Orlando, Fla., in early December.

The smart pumps are programmed with patient, drug, and dose parameters, then they stop healthcare workers when the dose is outside the recommended range. The range is typically preset by individual hospitals, with their drug library and dosing limits.

The culture of an organization has a bearing on whether pump errors are reported, said Sharon Steingass, professional practice leader, City of Hope National Medical Center in Duarte, Calif. "The systems we use for reporting are cumbersome, and they still put the fear of retaliation in us. Event data must be used in a constructive manner, not punitively," she declared.

These smart pump infusion "events" should be viewed as potential errors and a risk-prevention opportunity, Steingass added. Reports from smart pump events can show organizations where they can improve, such as better describing drugs and their multiple names in the facility's drug library. "Maybe the description is too confusing, or maybe the rates were set too conservatively," Steingass noted.

As a facility implements smart pump technology, a multidisciplinary team should decide which healthcare providers are going to analyze the data and how often they will communicate with the staff about potential and actual errors, "so they understand what kinds of things are occurring," Steingass said. She recommended that doctors, nurses, and pharmacists talk about smart pump infusion events and solutions. "You'll get a 360-degree view of why this is happening and keep events from occurring," she explained.

The benefits of smart pumps, the panel agreed, is that they act as a "black box," 24 hours a day, to record events and potential events. They can identify certain times of the day that are problematic, or types of staff who are having a higher rate of errors.

When looking at times of day when the most events occurred, Hope National Medical Center found that there were more events at 7:00 A.M. and at noon, during nurses' shift changes. Since nurses were in a hurry to leave, they'd put in the order to the pharmacist right before their shift change. After examining the events, the facility found that "it might not be a good idea to change the bag at shift changes," Steingass said.

Also, the hospital found that more events were occurring when the patients' families were in the room, asking the nurses questions. "The nurse needs to say, 'Let me program this device, then I'll answer your questions,'" Steingass said.

It is not enough for a facility to have a voluntary reporting system and a multidisciplinary team that discusses solutions, said Philip Schneider, clinical professor with Ohio State University College of Pharmacy. Instead, he suggested talking with staff about small changes they could make within the next week or month during weekly or monthly meetings. "It's easy to get into analysis paralysis: We end up taking more time to adopt the change or make improvements than we really should," he said.

Also, to prevent errors, nurses, pharmacists, and other staff cannot rely solely on the technology to set doses, said Jim Eskew, director of pharmacy at Clarion Health Partners in Indianapolis. While dosing guidelines are programmed into the pumps, he warned they often must be adjusted by patient and situation to prevent errors.

In addition, simple entry errors must be avoided. When Clarion Health surveyed its 1,400-bed facility, out of 2.8 million infusion pump starts, the pumps had to be reprogrammed 1,748 times over a one-year period. Eskew told the audience that 1,010 of those alerts "were for doses exceeding 10 times the maximum limit." The nurse accidentally entered a dose of 200 units, for example, when it should have been 20. Typically, those mistakes are quickly caught and the pump is reprogrammed, he said.