Human-Based Errors Involving Smart Infusion Pumps: A Catalog of Error Types and Prevention Strategies

Evolution of Intravenous Medication Errors and Preventive Systemic Defenses in Hospital Settings-A Narrative Review of Recent Evidence

OBJECTIVES

Intravenous drug administration has been associated with severe medication errors in hospitals. The present narrative review is based on a systematic literature search, and aimed to describe the recent evolution in research on systemic causes and defenses in intravenous medication errors in hospitals.

METHODS

This narrative review was based on Reason's theory of systems-based risk management. A systematic literature search covering the period from June 2016 to October 2021 was conducted on Medline (Ovid). We used the search strategy and selection criteria developed for our previous systematic reviews. The included articles were analyzed and compared to our previous reviews.

RESULTS

The updated search found 435 articles. Of the 63 included articles, 16 focused on systemic causes of intravenous medication errors, and 47 on systemic defenses. A high proportion (n = 24, 38%) of the studies were conducted in the United States or Canada. Most of the studies focused on drug administration (n = 21/63, 33%) and preparation (n = 19/63, 30%). Compared to our previous review of error causes, more studies (n = 5/16, 31%) utilized research designs with a prospective risk management approach. Within articles related to systemic defenses, smart infusion pumps remained most widely studied (n = 10/47, 21%), while those related to preparation technologies (n = 7/47, 15%) had increased.

CONCLUSIONS

This narrative review demonstrates a growing interest in systems-based risk management for intravenous drug therapy and in introducing new technology, particularly smart infusion pumps and preparation systems, as systemic defenses. When introducing new technologies, prospective assessment and continuous monitoring of emerging safety risks should be conducted.

Optimizing the Use of Dose Error Reduction Software on Intravenous Infusion Pumps

BACKGROUND AND OBJECTIVES

Intravenous infusions have the potential to cause significant harm in patients and are associated with a high rate of adverse drug events and medication errors. Infusion pumps with dose error reduction software (DERS) can be used to reduce errors by establishing safe infusion parameters. In 2019, a quality improvement project was initiated with the aim to increase DERS compliance from 46% to 75% at our specialty institution by October 1, 2022.

METHODS

An interdisciplinary group was tasked with improving compliance with DERS by identifying key drivers, including informed staff, engaged staff, and an accurate smart pump library. We used the Model for Improvement framework to guide this improvement project, and Plan-Do-Study-Act (PDSA) cycles were used to plan for interventions. PDSA cycles included drug library updates, education, and unit-level compliance reporting. Weekly average DERS compliance was monitored as the outcome measure, and weekly pump alerts per 100 infusions were monitored as a balancing measure; statistical process control charts were used to monitor measures from 2018 to 2022.

RESULTS

Over the course of 25 months, 8 PDSA cycles resulted in 5 centerline improvements from a baseline mean of 46% to a final mean of 78%. Pump alerts per 100 infusions decreased from 15.9 to 6.4 with the first PDSA cycle and then continued to decrease to 3.9 with subsequent interventions.

CONCLUSIONS

Although features like DERS can help ensure safe medication administration, continuous improvement efforts to increase DERS compliance without increasing alert burden are needed to ensure that benefits of this technology are optimized.

Data-based program management of system-wide IV smart pump integration

PURPOSE

Smart pump bidirectional interoperability offers automated infusion programming and documentation that can improve patient safety and workflow efficiency. This technology has been poorly implemented across US hospitals, and there is little guidance on the tracking or monitoring of interoperability systems. The purpose of this report is to describe the successful implementation of intravenous (IV) smart pump interoperability in a large health system.

SUMMARY

Bidirectional IV smart pump interoperability and compliance monitoring were implemented across a large Midwestern health system using ICU Medical's Plum 360 and LifeCare PCA devices and Smith Medical's MedFusion 4000 Syringe Pump devices. The hospital system's experience in implementing and monitoring IV smart pump compliance using automated reports and a dedicated medication safety integration nurse is described. Compliance trends suggest that the implementation of IV smart pump interoperability has achieved a reduction in programming outside of the dose error reduction system, manual overrides, and IV medication administration error rates.

CONCLUSION

The monitoring of smart pump compliance has had demonstrated benefits in investigating usability concerns, recognizing system errors, and identifying increased needs for nurse training. This program can serve as an example for other healthcare systems adopting IV smart pump interoperability.

Prioritizing Patient Safety: Analysis of the Procurement Process of Infusion Pumps in Spain

To understand whether patient safety and human factors are considered in healthcare technology procurement, we analyzed the case of infusion pumps as their use critically affects patient safety. We reviewed infusion pump procurements in the Spanish Public Sector Procurement Database. Sixty-three batches in 29 tenders for supplying 12.224 volumetric and syringe infusion pumps and consumables for an overall budget of EUR 30.4 M were identified and reviewed. Concepts related to "ease of use" were identified in the selection requirements of 35 (55.6%) batches, as part of the criteria for the selection of pumps in 23 (36.5%) batches, related to "intuitiveness" in the selection requirements of 35 (55.6%) batches, and in the criteria in 10 (15.9%) batches. No method to evaluate the ease of use, intuitiveness, or usability was mentioned. A review of the procurement teams responsible for the evaluation of the tenders showed no reported human factors or patient safety expertise. We conclude that infusion pump procurement considers usability as a relevant criterion for selection. However, no human factor experts nor specific methods for evaluation of the technology in this field are usually defined. Potential room for refining the selection of healthcare technology to improve patient safety is detected.

Increasing the margin of patient safety for periodontal and implant treatments: The role of human factors

Early complications following periodontal and dental implant surgeries are typically attributed to technique or poor biological response, ignoring the possibility of the human element. Interestingly, significant experience is not correlated with increased success, whereas evidence supports the impact of clinical behavior on patient outcome. This is the result of errors, much like those scrutinized in other high-risk technical fields, such as aviation. What can be surprising is that those who make these errors are very well acquainted with best practices. Given this, how is it possible for the conscientious practitioner to fail to apply protocols that are nonetheless very well known? Recently, the concepts of human and organizational factors have been translated to medicine, though dentistry has been slow to recognize their potential benefit. This review lists specific human factor behaviors, such as use of checklists and crew resource management, which might improve postsurgical outcome.

Smart Use of Smart Infusion Pumps

Smart infusion pumps have reduced but not eliminated medication errors. These errors are frequently related to misuse or underuse of the safety features of the pump.The Institute for Safe Medication Practices offers safety considerations for using smart pumps and suggestions for maintaining an institution's smart pump drug library.

Developing Strategic Recommendations for Implementing Smart Pumps in Advanced Healthcare Systems to Improve Intravenous Medication Safety

Avoidable harm associated with medication is a persistent problem in health systems and the use of preprogrammed infusion devices ('smart pumps') and data monitoring is seen as a core approach to mitigating and reducing the incidence of these harms. However, smart pumps are costly to procure, configure and maintain (in both human and financial terms) and are often poorly implemented. Variation in the manner in which medicines are prepared and used within complex modern healthcare systems exacerbates these challenges, and a strategic human-centred approach is needed to support their implementation. A symposium of 36 clinical and academic medication safety experts met virtually to discuss the current 'state of the art' and to propose strategic recommendations to support the implementation of medication administration technology to improve medication safety. The recommendations were that health systems (1) standardise infusion concentrations to facilitate the development of ready-to-administer formulations of frequently used medicines, and support 'out of the box' programming of infusion devices; (2) develop and implement drug libraries using human-centred approaches and the aforementioned standard concentrations, with a theoretical understanding of how devices are used in practice; (3) develop standardised metrics and outcomes to support the interpretation of data produced by infusion devices; (4) involve all stakeholders in the development of drug libraries and metrics to ensure broad understanding of the devices, their benefits and limitations; and (5) leverage input into device design, working with manufacturers and users. Using this strategic approach, it is then possible to envisage and plan real-world implementation studies using a uniform approach to quantify improvements in safety, efficiency and cost effectiveness.

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study

Introduction

The use of intravenous administration systems with dose error reduction software (DERS) is advocated to mitigate avoidable medication harm. No large-scale analysis of UK data has been attempted. This retrospective descriptive study aimed to estimate the prevalence of hard limit events and to estimate the potential severity of DERS events.

Method

Twelve months of DERS data was obtained from two NHS trusts in England. Definitions for drug categories and clinical areas were standardised and an algorithm developed to extract hard maximum (HMX) events. Subject matter experts (SMEs) were asked to rate severity of all HMX events on a scale of 0 (no harm) to 10 (death). These were analysed by clinical area and drug category, per 1000 administrations.

Results

A total of 745 170 infusions were administered over 644 052 patient bed days (PBDs). 45% of these (338 263) were administered with DERS enabled. HMX event incidence across the whole dataset was 17.9/1000 administrations (95% CI 17.5 to 18.4); 9.4/1000 PBDs (95% CI 9.2 to 9.7). 6067 HMX events were identified. 4604 were <2-fold deviations and excluded. HMX were identified in all drug categories. The highest incidence was antibacterial drugs (2.21%; 95% CI 2.13 to 2.29). Of the 1415 HMX events reviewed by SMEs, 747 (52.6%) were low/no harm. Drugs with greatest potential harm were antiarrhythmics (21.8/1000 administrations; 95% CI 16.3 to 29.1), parenteral anticoagulants (24.16/1000 administrations; 95% CI 15.3 to 37.9) and antiepileptics (20.86/1000 administrations; 95% CI 16.4 to 26.5). DERS has prevented severe harm or death in 110 patients in these hospitals. Medical and paediatric areas had higher prevalence of potentially harmful HMX events, but these were probably related to profile design.

Conclusion

Compliance with DERS in this study was 45%. DERS events are common, but potential harm is rare. DERS events are not related to specific clinical areas. There are some issues with definition and design of drug profiles that may cause DERS events, thus future work should focus on implementation and data standardisation for future large-scale analysis.

Exploration of an Alarm Sensor to Detect Infusion Failure Administered by Syringe Pumps

Incorrect medication administration causes millions of undesirable complications worldwide every year. The problem is severe and there are many control systems in the market, yet the exact molecular composition of the solution is not monitored. Here, we propose an alarm sensor based on UV-Vis spectroscopy and refractometry. Both methods are non-invasive and non-destructive as they utilize visible light for the analysis. Moreover, they can be used for on-site or point-of-care diagnosis. UV-Vis-spectrometer detect the absorption of light caused by an electronic transition in an atom or molecule. In contrast a refractometer measures the extent of light refraction as part of a refractive index of transparent substances. Both methods can be used for quantification of dissolved analytes in transparent substances. We show that a sensor combining both methods is capable to discern most standard medications that are used in intensive care medicine. Furthermore, an integration of the alarm sensor in already existing monitoring systems is possible.

Convolutional neural network-based ambient light-independent panel digit surveillance technique for infusion pumps

For effective patient therapy and improved patient safety, it is critical to administer medication accurately in accordance with doctor's prescription. However, accidents owing to the erroneous programing of infusion pumps caused by users have been consistently reported in several documents. In this study, the authors propose a novel surveillance technique for infusion pumps to continuously monitor the variations in panel digits using a convolutional neural network model, and evaluate the performance of the implemented technique. During the experimental evaluation, 1st-step ROIs and 2nd-step ROIs were successfully extracted from the frame images regardless of the ambient lighting conditions. The final accuracies of the implemented CNN model are 99.9% for both the training (172,800 images) and validation (1080 images) dataset while the final losses for the training and validation datasets are 0.48 and 0.45 after 13th epoch, respectively. In the 24-h continuous monitoring test, the accuracy of the model for volume recognition considering all the 1440 measurements (960 for day-lighting and 480 for night-lighting) is 95.5%, whereas in day-lighting and night-lighting modes the accuracies of the model are 98.2% and 90.0%, respectively. Based on these experimental results, the proposed surveillance technique incorporating infusion pumps is expected to improve the safety of patients who need long-term treatments via infusion pumps, reducing the burden on the nurses and hospitals.