Advancing medication infusion safety through the clinical integration of technology

Implementation of Smart Infusion Pumps: A Scoping Review and Case Study Discussion of the Evidence of the Role of the Pharmacist

“Smart” infusion pumps include built in drug error reduction software which uses a drug library. Studies have reported the drug library build should be undertaken by a multidisciplinary team, including a pharmacist; however, the extent or nature of the input required by the pharmacist for greatest benefit is unknown. This review aimed to identify key factors for the implementation of the smart infusion pumps, with a focus on the role of pharmacists and compare this to the experience from a case study. A literature review was conducted using Embase and Ovid Medline, and 13 eligible papers were found. Predominant themes relating to the pharmacist’s role and successful implementation of the smart infusion pumps were determined. Key factors for success included team involvement across the entire process from procurement, set-up through to implementation including risk assessment and device distribution, and training, which were comparable to the case study experience. Few studies described the extent or details of the pharmacist’s responsibilities.

Technology Isn't the Half of It: Integrating Electronic Health Records and Infusion Pumps in a Large Hospital

BACKGROUND

Although adoption of "smart" infusion pumps has improved intravenous medication administration safety, pump integration with electronic health records (EHRs) remains rare. Early-adopter hospitals have recently implemented intravenous clinical integration (IVCI) to allow bidirectional communication between their EHRs and infusion pumps. However, the challenges and strategies involved in IVCI implementation have not been described.

METHODS

A qualitative description of one hospital's IVCI implementation was conducted. The research team interviewed 33 pharmacists, technologists, clinicians, nurse managers, educators, and organizational leaders; observed nurses on five units using EHR-integrated pumps; and attended nurse training. Interview notes and transcripts were analyzed to describe IVCI implementation, highlighting its effects on clinicians and the organization.

RESULTS

Motivations for implementation included a culture of innovation, simultaneous pump and EHR upgrades, and belief that IVCI would improve patient safety. Proactive planning included a simultaneous go-live across selected units, financial investment, multidisciplinary planning teams, and clinical training. Challenges included lack of direct communication between EHR and pump vendors, nonstandardized unit-specific drug libraries, and unit- and nurse-specific variation in workflows for administering infusions. Mitigation strategies included serving as messenger between vendors, conducting hospitalwide efforts to standardize drug libraries and workflows, and standardizing organizational policies. Lessons learned included that IVCI adoption was as much a nursing workflow and organizational policy intervention as a technological implementation.

CONCLUSION

Integrating infusion pumps and EHRs involves much more than installing new technologies. Hospitals considering IVCI should prepare to undertake significant simultaneous changes to organizational policies and clinician workflows.

A Scoping Review of the Quality and the Design of Evaluations of Mobile Health, Telehealth, Smart Pump and Monitoring Technologies Performed in a Pharmacy-Related Setting

Background: There is currently a need for high quality evaluations of new mobile health, telehealth, smart pump and monitoring technologies undertaken in a pharmacy-related setting. We aim to evaluate the use of these monitoring technologies performed in this setting. Methods: A systematic searching of English articles that examined the quality and the design of technologies conducted in pharmacy-related facilities was performed using the following databases: MEDLINE and Cumulative index to Nursing and Allied Health Literature (CINAHL) to identify original studies examining the quality and the design of technologies and published in peer-reviewed journals. Extraction of articles and quality assessment of included articles were performed independently by two authors. Quality scores over 75% are classed as being acceptable using a "relatively conservative" quality benchmark. Scores over 55% are included using a "relatively liberal" cut-off point. Results: Screening resulted in the selection of 40 formal evaluations. A substantial number of studies (32, 80.00%) were performed in the United States, quantitative in approach (33, 82.50%) and retrospective cohort (24, 60.00%) in study design. The most common pharmacy-related settings were: 22 primary care (55.00%); 10 hospital pharmacy (25.00%); 7 community pharmacy (17.50%); one primary care and hospital pharmacy (2.50%). The majority of the evaluations (33, 82.50%) reported clinical outcomes, six (15.00%) measured clinical and economic outcomes, and one (2.50%) economic only. Twelve (30.00%) quantitative studies and no qualitative study met objective criteria for "relatively conservative" quality. Using a lower "relatively liberal" benchmark, 27 quantitative (81.82%) and four qualitative (57.41%) studies met the lower quality criterion. Conclusion: Worldwide, few evaluations of mobile health, telehealth, smart pump and monitoring technologies in pharmacy-related setting have been published.Their quality is often below the standard necessary for inclusion in a systematic review mainly due to inadequate study design.

Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit

Background

Timely identification of medication administration errors (MAEs) promises great benefits for mitigating medication errors and associated harm. Despite previous efforts utilizing computerized methods to monitor medication errors, sustaining effective and accurate detection of MAEs remains challenging. In this study, we developed a real-time MAE detection system and evaluated its performance prior to system integration into institutional workflows.

Methods

Our prospective observational study included automated MAE detection of 10 high-risk medications and fluids for patients admitted to the neonatal intensive care unit at Cincinnati Children's Hospital Medical Center during a 4-month period. The automated system extracted real-time medication use information from the institutional electronic health records and identified MAEs using logic-based rules and natural language processing techniques. The MAE summary was delivered via a real-time messaging platform to promote reduction of patient exposure to potential harm. System performance was validated using a physician-generated gold standard of MAE events, and results were compared with those of current practice (incident reporting and trigger tools).

Results

Physicians identified 116 MAEs from 10 104 medication administrations during the study period. Compared to current practice, the sensitivity with automated MAE detection was improved significantly from 4.3% to 85.3% (P = .009), with a positive predictive value of 78.0%. Furthermore, the system showed potential to reduce patient exposure to harm, from 256 min to 35 min (P < .001).

Conclusions

The automated system demonstrated improved capacity for identifying MAEs while guarding against alert fatigue. It also showed promise for reducing patient exposure to potential harm following MAE events.

Benefits and risks of using smart pumps to reduce medication error rates: a systematic review

BACKGROUND

Smart infusion pumps have been introduced to prevent medication errors and have been widely adopted nationally in the USA, though they are not always used in Europe or other regions. Despite widespread usage of smart pumps, intravenous medication errors have not been fully eliminated.

OBJECTIVE

Through a systematic review of recent studies and reports regarding smart pump implementation and use, we aimed to identify the impact of smart pumps on error reduction and on the complex process of medication administration, and strategies to maximize the benefits of smart pumps.

METHODS

The medical literature related to the effects of smart pumps for improving patient safety was searched in PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (2000-2014) and relevant papers were selected by two researchers.

RESULTS

After the literature search, 231 papers were identified and the full texts of 138 articles were assessed for eligibility. Of these, 22 were included after removal of papers that did not meet the inclusion criteria. We assessed both the benefits and negative effects of smart pumps from these studies. One of the benefits of using smart pumps was intercepting errors such as the wrong rate, wrong dose, and pump setting errors. Other benefits include reduction of adverse drug event rates, practice improvements, and cost effectiveness. Meanwhile, the current issues or negative effects related to using smart pumps were lower compliance rates of using smart pumps, the overriding of soft alerts, non-intercepted errors, or the possibility of using the wrong drug library.

CONCLUSION

The literature suggests that smart pumps reduce but do not eliminate programming errors. Although the hard limits of a drug library play a main role in intercepting medication errors, soft limits were still not as effective as hard limits because of high override rates. Compliance in using smart pumps is key towards effectively preventing errors. Opportunities for improvement include upgrading drug libraries, developing standardized drug libraries, decreasing the number of unnecessary warnings, and developing stronger approaches to minimize workarounds. Also, as with other clinical information systems, smart pumps should be implemented with the idea of using continuous quality improvement processes to iteratively improve their use.