Reducing Intermittent Infusion Syringe Pump Errors via Weight-Based Safety Parameters

Transcription

1 Reducing Intermittent Infusion Syringe Pump Errors via Weight-Based Safety Parameters Alison Bloomquist and Laura Seiberlich Abstract Historically, smart infusion pumps with dose error reduction software were implemented to improve safety associated with programming of continuous infusion modes on large-volume infusion pumps. Much of the published literature related to smart infusion pumps and safety alerts is focused on continuous medication infusions, with little available information related to their use with intermittent infusions. As a result of the focus on continuous infusions, an impression exists that intermittent infusions are less prone to programming errors and/or do not require comparably rigorous safety parameters, such as use of weightbased medication programming. Methods: A retrospective study was conducted with data from 10 pediatric inpatient hospitals, all of which used syringe infusion pumps for intermittent medications, to describe the impact of weight-based safety parameters on the occurrence of potential programming errors. The data were analyzed based on recorded safety alerts and alert triggers for weight-based (dose/kilogram/time) and non weight-based (volume-over-time [VOT]) intermittent infusions. Results: Data from a total of 4,162 pumps, 943,448 total infusions, and 810,359 intermittent infusions between January 1 and December 31, 2013, were reviewed. Weight-based infusions had a greater percentage of safety alerts (83.3%) compared with VOT infusions (16.7%). Conclusion: Weight-based intermittent infusion modes can prevent programming errors and, compared with non weight-based intermittent infusion modes, can be used to improve safety in the pediatric population. Additional research should be conducted to confirm a decrease in adverse drug events resulting from implementation of weight-based safety parameters. Because intravenous (IV) medications are involved in more than one-half of potential adverse drug events (ADEs), interest exists in improving the medication administration process. 1 3 Smart IV infusion pumps were designed and introduced with dose error reduction software, also known as medication or drug libraries, to help prevent medication delivery errors. 4 The software was initially developed to increase safety of programming continuous infusion modes on large-volume infusion pumps, and as a result, this has been the delivery mode of interest in published literature. 5,6 The focus on continuous medications has generated a perception that intermittent infusions are less prone to programming errors and do not require rigorous safety parameters, About the Authors Alison Bloomquist, PharmD, is a pharmacy clinical resource specialist at Smiths Medical, ASD, Inc. in St. Paul, MN. alison.bloomquist@ smiths-medical.com Laura Seiberlich, MS, is a clinical research manager at Smiths Medical, ASD, Inc. in St. Paul, MN. laura. seiberlich@smiths-medical.com Horizons Fall

2 such as use of weight-based medication programming. 6,7 Syringe infusion pumps, which are commonly used for intermittent infusions in populations that are at a greater risk for medication errors (e.g., pediatrics), are of particular concern. 8,9 Published reports of intermittent infusion errors have included medication overdoses or rapid infusions leading to serious injury or even death. 6,10 13 Objective We sought to describe the impact of weightbased safety parameters on the occurrence of programming errors for intermittent syringe pump infusions. Methods Data from 10 pediatric inpatient hospitals using Medfusion 4000 Syringe Infusion Pumps and PharmGuard Server Software (Smiths Medical, St. Paul, MN) were evaluated retrospectively between Jan. 1 and Dec. 31, The data were analyzed based on recorded safety alerts and alert triggers for weight-based (dose/kg/time) and non weight-based (volume-over-time [VOT]) intermittent infusions. Safety alerts included abandoned infusions, soft limit reprogramming, soft limit overrides, and hard limit alerts. A safety alert was defined as a value programmed outside of the defined limits. Alert triggers were the programming parameters in the medication library for the infusion mode used (e.g., time, volume, weight, dose, concentration). Categorical variables were analyzed using the chi-square test. Results Data from a total of 4,162 pumps, 943,448 total infusions, and 810,359 intermittent infusions were reviewed. Of the 810,359 intermittent infusions, weight-based infusions accounted for 419,296 (51.7%), VOT infusions for 363,408 (44.9%), and other intermittent modes for 27,655 (3.4%) (Figure 1). Of the 782,704 weight-based and VOT infusions, 39,049 (4.9%) safety alerts were recorded, with at least one safety alert reported in 6.9% (29,324) and 1.7% (5,880) of weight-based and VOT infusions, respectively. Weight-based infusions had a greater percentage of safety alerts (83.3%) compared with VOT infusions ((16.7%; P < 0.001) (Figure 2). The programming parameters that triggered safety alerts were dose (weight based: 59.7%; VOT: 0%), main time (weight based: 27.3%; VOT: 76.6%), weight (weight based: 9.2%; VOT: 0%), volume (weight based: 0%; VOT: 23.4%), and concentration (weight based: 3.8%; VOT: 0%) (Figure 3). Weight-based infusions also had a greater percentage of safety alerts for each safety alert type: soft limit overrides (weight based: 88.8%; VOT: 11.2%), hard limit alerts (weight based: 74.4%; VOT: 25.6%), soft limit reprograms (weight based: 85.1%; VOT: 14.9%), and abandoned infusions (weight based: 88.9%; VOT: 11.1%) (Figure 4). Figure 1. Breakdown of infusion types 32 Horizons Fall 2015

3 The top 10 intermittent medications used for the weight-based and VOT infusions and the number of infusions are provided in Table 1. A substantial portion of VOT infusions were made up of medications (140,130 infusions) and Non-PharmGuard infusions (117,832 infusions). (Note: The term medications is used as a catch-all infusion pump program in Figure 2. Safety alerts by infusion type certain libraries for any intermittent infusions, and Non-PharmGuard infusions are those that are programmed outside of a medication library using the manual mode of volume/ time.) Combined, these account for 71% (257,962) of the VOT infusions and 33% of all weight-based and VOT intermittent infusions. Discussion In this study, intermittent infusion modes accounted for 85% of all syringe pump infusions reviewed, though only one-half of the infusions had the programming rigor of using weight-based parameters. Use of weight-based infusions may require slightly more programming time for clinicians; however, weight-based infusions contain additional parameters (concentration, dose, and weight) for which safety limits can be defined. Each weight-based parameter can have hard and soft upper and lower limits defined within the specific medication protocol, which will alert the clinician if the programmed value is Figure 3. Percent of safety alerts by trigger Horizons Fall

4 outside of the acceptable range. Hard limits prevent the clinician from programming outside of the defined range, and soft limits require the user to reprogram the value within the defined limits or create an override event to continue programming with a value outside of the soft limit range. Weight-based infusions triggered significantly more safety alerts than infusions that were programmed using VOT settings. Weight-based infusions also had a significantly greater percentage of safety alerts for each safety alert type. Safety alerts appear during the programming process, before the infusion is started, and therefore can decrease the number of medication delivery errors. Although the majority of the top 10 weightbased medications were antibiotics, medications with greater potential for toxicity, such as furosemide (15,592 infusions) and morphine (13,034 infusions), were not uncommon. The presence of additional programming parameters is important to ensure patient safety. A recent report from a national study of IV medication errors noted that morphine was the second highest medication associated with errors and frequently resulted in ADEs. 13 Although not among the top 10 medications in the current study, Institute for Safe Medication Practices (ISMP) high-alert medications, such as potassium (7,771 infusions), promethazine (1,154 infusions), and magnesium (4,288 infusions), also were infused using intermittent infusion modes. 14 Because 70% of the VOT infusions were medications or Non-PharmGuard, the Figure 4. Safety alerts by infusion type 34 Horizons Fall 2015

5 actual medications infused within this category are unknown. However, it is likely that they would include several, if not all, of the medications found on the weight-based medication program list. Transitioning to individual weight-based medication programs versus catch-all medication programs or basic mode infusions could increase the amount of infusion data available for evaluation, and the additional programming parameters could result in more errors being caught. Weight-based medications (No. infusions) Volume-over-time medications (No. infusions) Ampicillin (30,263) Medication a (140,130) Vancomycin (27,760) Non-Pharmguard b (117,832) Clindamycin (18,874) Formula (29,196) Furosemide (15,592) Flush (26,431) Ceftriaxone (15,578) Breast milk (22,454) Ranitidine (15,422) Enteral feeding (8,673) Gentamicin (14,105) Lipids (4,003) Ondansetron (13,544) Albumin (2,668) Morphine (13,034) Intermittent feeding (2,045) Cefotaxime (13,014) Packed red blood cells (2,043) Table 1. Top 10 weight-based and volume-over-time intermittent medications a Medication is a catch-all term for a medication program used when an intermittent medication was infused. b Non-PharmGuard indicates infusions that did not use a medication program but instead were programmed using a manual mode (volume/time) on the pump. The Spark You Need The Standard for Medical Equipment ANSI/AAMI ES :2005/2012 gives you: Track changes so you can easily see amendment updates. A choice of formats, including a popular compact version. Order Code: , PDF, CD, or PE List $850 / AAMI member $510 Only need the Amendment? Order Code: A or A-PDF List $225 / AAMI member $135 AAMI Standards and Recommended Practices ANSI/AAMI ES :2005/(R)2012 and A1:2012, C1:2009/(R)2012 and A2:2010/(R)2012 (Consolidated Text) Medical electrical equipment Part 1: General requirements for basic safety and essential performance (IEC :2005, MOD). Not an AAMI Member? Join us today. Order your copy today! Visit Horizons Fall

6 Disclosure The authors are employees of Smiths Medical, ASD, Inc., manufacturer of the Medfusion 4000 syringe infusion pump. Acknowledgments To Dr. Brian Jacobs; Jason Corcoran, PharmD; and Jeffrey Hooper from Children s National Health System for providing feedback on the manuscript and to the nine additional organizations that contributed infusion data. Limitations The data from the current study were retrospectively evaluated from only one commercially available infusion pump, and a direct link between a safety alert and an ADE cannot be determined. Additional research should be conducted to confirm a decrease in ADEs resulting from implementation of weight-based safety parameters. Conclusion This retrospective study shows that use of a smart infusion pump and weight-based safety limits for intermittent infusions can help in avoiding ADEs. Weight-based intermittent infusions account for a large percentage of all medications delivered using a syringe pump, and use of the mode prevents potential programming errors, such as rapid infusions or overdoses, and therefore is preferable to a non weight-based infusion. n References 1. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16): Moyen E, Camiré E, Thomas H. Clinical review: medication errors in critical care. Crit Care. 2008;12(2): American Society of Health-System Pharmacists. Proceedings from a summit on preventing patient harm and death from IV medication errors. Am J Health Syst Pharm. 2008; 65: Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2006:100 1, Skledar SJ, Niccolai CS, Schilling D, et al. Qualityimprovement analytics for intravenous infusion pumps. Am J Health Syst Pharm. 2013;70(8): Horizons Fall Danello SH, Maddox RR, Schaack GJ. Intravenous infusion safety technology: return on investment. Hosp Pharm. 2009;44(8): Harding AD. Increasing the use of smart pump drug libraries by nurses: a continuous quality improvement project. Am J Nurs. 2012;112(1): Johnson KB, Lehmann CU, et al. Electronic prescribing in pediatrics: toward safer and more effective medication management. Pediatrics Apr; 131(4):e Lehmann CU, Council on Clinical Information Technology. Pediatric aspects of inpatient health information technology systems. Pediatrics. 2015;135(3):e Manrique-Rodriguez S, Sanchez-Galindo AC, Lopez-Herce J, et al. Impact of implementing smart infusion pumps in a pediatric intensive care unit. Am J Health Syst Pharm. 2013;70(1): Wesolowski C. Preventing medication errors in hospitalized children. Am J Health Syst Pharm. 2009;66(3): Ostrom C. Baby dies at Seattle Children s hospital after overdose. Available at: com/seattle-news/baby-dies-at-seattle-childrenshospital-after-overdose. Accessed May 29, Blum K. Multiple IV lines pose safety issues. Available at: com/viewarticle.aspx?d=clinical&d_ id=50&i=may+2015&i_id=1181&a_id= Accessed May 29, Institute for Safe Medication Practices. ISMP list of high-alert medications in acute care settings: Available at: institutionalhighalert.asp. Accessed May 29, 2015.

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