Dose Error Reduction Software Research Articles

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

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. 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. 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. 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.

Time to review how injectable medicines are prepared and administered in European hospitals

It has been known, for decades, that the use of injectable medicines in European hospitals has been associated with frequent medication errors, some of which cause preventable severe harms and deaths. There have been national and European inquiries and reports concerning improving patient safety by recommending greater use of pharmacy aseptic preparation services and provision of ready-to administer injectables, which have not been widely implemented.In England experience of treating patients with COVID-19 infections has brought into focus other benefits of significantly extending pharmacy aseptic preparation services. These benefits include saving nursing time, having systems in place which have resilience and capacity, reducing variation in practice, improving clinical staff and patient experience, and enabling more injectable medicines to be administered to patients at home. It has also been recognised that more action is required to standardise policies and procedures for injectable medicines and implement the use of smart infusion devices with dose error reduction software, to help minimise drug administration errors.Hospital pharmacists have a key role in developing these services to bring European hospitals more in line with those provided by hospital pharmacies in North America.

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

IntroductionThe 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...

Dose error reduction software in medication safety risk management \u2013 optimising the smart infusion pump dosing limits in neonatal intensive care unit prior to implementation

BackgroundSmart infusion pumps with dose error reduction software can be used to prevent harmful medication errors. The aim of this study was to develop a method for defining and assessing optimal dosing limits in a neonatal intensive care unit’s smart infusion pump drug library by using simulation-type test cases developed based on medication error reports.MethodsThis mixed-methods study applied both qualitative and quantitative methods. First, wrong infusion rate-related medication errors reported in the neonatal intensive care unit during 2018–2019 were explored by quantitative descriptive analysis and qualitative content analysis to identify the error mechanisms. The researchers developed simulation-type test cases with potential errors, and a literature-based calculation formula was used to set upper soft limits to the drug library. The limits were evaluated by conducting programming of pumps without errors and with potential errors for two imaginary test patients (1 kg and 3.5 kg).ResultsOf all medication errors reported in the neonatal intensive care unit, 3.5% (n = 21/601) involved an error or near-miss related to wrong infusion rate. Based on the identified error mechanisms, 2-, 5-, and 10-fold infusion rates, as well as mix-ups between infusion rates of different drugs, were established as test cases. When conducting the pump programming for the test cases (n = 226), no alerts were triggered with infusion rates responding to the usual dosages (n = 32). 73% (n = 70/96) of the erroneous 2-, 5-, and 10-fold infusion rates caused an alert. Mix-ups between infusion rates triggered an alert only in 24% (n = 24/98) of the test cases.ConclusionsSimulation-type test cases can be applied to assess the appropriateness of dosing limits within the neonatal intensive care unit’s drug library. In developing the test cases, combining hospital’s medication error data to other prospective data collection methods is recommended to gain a comprehensive understanding on mechanisms of wrong infusion rate errors. After drug library implementation, the alert log data and drug library compliance should be studied to verify suitability of dosing limits.

The Impact of Smart Pump Interoperability on Errors in Intravenous Infusion Administrations: A Multihospital Before and After Study.

ObjectiveThe objective of this study was to assess the frequency, type, and severity of errors associated with intravenous medication administration before and after smart pump interoperability.MethodsWe conducted an observational study at a community healthcare system before and after implementing smart pump interoperability. Point prevalence methodology was used to collect data on medication administration and errors in adult inpatient settings.ResultsObservations were completed for 350 infusions preintervention (178 patients) and 367 postintervention (200 patients). Total errors significantly decreased from 401 (114.6 per 100 infusions) to 354 (96.5 per 100 infusions, P = 0.02). Administration errors decreased from 144 (41.1 per 100 infusions) to 119 (32.4 per 100 infusions, P = 0.12). Expired medication errors significantly reduced from 11 (3.1 per 100 infusions) to 2 (0.5 per 100 infusions, P = 0.02). Errors involving high-risk medications significantly reduced from 45 (12.8 per 100 infusions) to 25 (6.8 per 100 infusions, P = 0.01). Errors involving continuous medications significantly reduced from 44 (12.6 per 100 infusions) to 22 (6.0 per 100 infusions, P = 0.005). When comparing programming type, manual programming resulted in 115 (77.2%) of administration and user documentation errors compared with 34 errors (22.8%) that occurred when autoprogramming was used. Of these, errors involving high-risk medications reduced from 21 (84.0%) to 4 (16.0%) after using autoprogramming.ConclusionsSmart pump interoperability resulted in a 16% reduction in medication administration errors. Despite using dose error reduction software and autoprogramming, some types of errors persisted. Further studies are needed to understand how technology use can be optimized.

Impact of a Review of a Smart Infusion Pump Library in Hematology/Oncology: Tailoring Content to Meet Specialty Needs.

Errors involving chemotherapy or intravenous medications may cause serious patient harm. Dose error reduction software (DERS) for "smart" infusion pumps offers additional safety protection for their administration. Our institution uses DERS software hospital-wide; however, the hematology/oncology areas were noted to have reduced compliance with DERS recommendations. In response, we sought to review the DERS content and survey hematology/oncology end users' satisfaction with the software. A multidisciplinary working group was formed to review the current DERS entries for medications, fluids, and blood products. The review included details such as dose, rate, and concentrations. Dose error reduction software compliance was determined using vendor-supplied Continuous Quality Improvement software. An electronic survey assessing clinicians' satisfaction with the current DERS library and any challenges in its use was conducted before and after the review. Ninety-one changes were made to 71 medications by the working group. Compliance with the DERS library went from 81.5% before the review to 87.3% after the review (P = 0.257). Fifty-eight survey responses were received (30 prereview and 28 postreview) with improvements in staff satisfaction with the DERS library (83.3%-92.8%, P < 0.05). Near-miss events changed after the review from 2 to 0, and the number of alerts caused by values outside the DERS library reduced from 8788 before the review to 3383 after the review (P ≤ 0.05). Review of a hematology/oncology DERS library found improvements that better met the needs of end users. Engagement with relevant stakeholders, in conjunction with ongoing communication and review, is required to improve compliance and satisfaction with DERS.

Make smart pumps work harder to keep patients safe

Smart pump errors, which involve both human and technical factors, can cause injury or death to patients. Fatigue and distractions plague many busy patient care units and frequently contribute to smart pump errors. Technical factors that lead to errors include overriding the drug library or using it incorrectly. In a new publication, Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS, The Joint Commission recommends eight actions hospitals can take to optimize safe smart pump use. Many of these suggestions involve the hospital’s pharmacy team. The Joint Commission first suggests that hospital leadership create multidisciplinary project teams for all things smart pump–related. “Unlike many other medical devices in use in health care, smart infusion pumps require an extensive multidisciplinary team to ensure they are used to their fullest potential,” said Heather Haug, PharmD, an analyst for Advocate Aurora Health in Milwaukee, who was not involved with The Joint Commission publication. “Not only does the nursing staff rely upon smart pumps for administering medications, but our anesthesiologists, respiratory therapists, and other interventional providers are encouraged and/or expected to utilize the same smart infusion pumps.” Dose error reduction software (DERS) is an integral part of the “smart” portion of the smart pump. This software usually contains a library of drug infusions a nurse can choose from when programming the pump. As long as the correct drug is chosen from the properly managed library, the patient is protected from an under- or overdose. The Joint Commission next suggests defining how the drug library will be created, tested, engaged with, and maintained. This is where the pharmacist’s involvement is critical. As the drug experts on the health care team, pharmacists are responsible for ensuring that the clinical data of the library (e.g., the maximum rate acceptable for heparin drip) are cohesive, as well as the operational data for the hospital. This operational data includes which drips are offered by the inpatient pharmacy for patient care. “What may be a logical ‘fix’ to a pharmacist [can be] an impractical workflow to the nurse,” said Haug. “Sometimes the smallest detail, like the way a pharmacy compounded I.V. bags, has the greatest impact in the ability of nurses [to utilize a smart pump] in the manner it was intended.” Although pharmacists are deeply involved in drug library management, hospitals still need to make sure that all clinical staff who use smart pumps are adequately prepared to do so. The Joint Commission suggests providing training as well as initial and annual competency assessments. In addition, the hospital’s culture should include the expectation for clinical staff to appropriately use the DERS within the smart pump. Applying workarounds or other methods to bypass the drug library defeats the purpose of the smart pump. To nurture this culture, The Joint Commission suggests monitoring alerts, overrides, recalls, adverse events, and close calls to evaluate compliance of smart pump usage. If the set-up of the DERS makes compliance difficult, it should be adjusted so that clinical staff have as few barriers as possible to using this technology, according to the publication. The Joint Commission’s next suggestion is to integrate the smart pump fleet within a hospital’s electronic health record (EHR). This allows for the importation of data from the EHR to avoid transcription errors that occur when interoperability is not engaged. Informatics stakeholders are a valuable resource for this integration work. The Joint Commission also suggests evaluating human and environmental factors that negatively impact smart pump usage. Workflow, staffing, distractions, glare, and user interfaces can be changed to ensure safe patient care. Calling upon human factors engineers or risk-based thinkers can assist with this work. Last, make sure a smart pump fleet is safe from security threats, The Joint Commission advises. Hackers are everywhere, and ensuring smart pumps are not attacked is necessary for safe patient care.

Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS

Editor's Note: For over two decades, The Joint Commission has developed and disseminated Sentinel Event Alerts (SEAs). SEAs identify specific types of adverse events and high-risk conditions, describe their underlying causes, and recommend steps to reduce risk and prevent future occurrences. Health care organizations should consider the information in SEAs when designing or redesigning processes, including specific suggestions contained in the alerts to mitigate risks. Recently, The Joint Commission decided that co-publishing SEAs in the Journal would help expand dissemination efforts by reaching beyond health care organizations to the broader quality and safety community, including researchers and policymakers. In this issue, we are proud to publish Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS (dose error reduction software). The SEA describes actions health care organizations can take to reduce the risk of errors caused by the misuse of smart infusion pumps, especially errors that can be avoided by the optimal use of DERS. We will co-publish future SEAs that we think would be of interest to the Journal's audience. We hope you enjoy this new addition to the Journal.

The Potential Role of Smart Infusion Devices in Preventing or Contributing to Medication Administration Errors: A Descriptive Study of 2 Data Sets.

ObjectivesErrors in medication administration are common, with many interventions suggested to reduce them. For intravenous infusion–related errors, “smart infusion devices” incorporating dose error reduction software are widely advocated. Our aim was to explore the role of smart infusion devices in preventing or contributing to medication administration errors using retrospective review of 2 complementary data sets that collectively included a wide range of errors with different levels of actual or potential harm.MethodsWe reviewed 216 medication administration errors identified from an observational study in clinical practice and 123 medication incidents involving infusion devices reported to a national reporting system. The impact of smart infusion devices in preventing or contributing to these errors was assessed by the research team and an expert panel.ResultsThe data suggest that use of any infusion device rather than gravitational administration may have prevented 13% of observed errors and 8% of reported incidents; additional reductions may be possible with standalone smart infusion devices, and further potential reductions with smart infusion devices integrated with electronic prescribing and barcode administration systems. An estimated 52% to 73% of errors that occurred with traditional infusion pumps could be prevented with such integrated smart infusion devices. In the few cases where smart infusion devices were used, these contributed to errors in 2 of 58 observed errors and 7 of 8 reported incidents.ConclusionsSmart infusion devices not only prevent some medication administration errors but can also contribute to them. Further evaluation of such systems is required to make recommendations for policy and practice.

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

To describe the benefits of smart infusion pump interoperability with an electronic medical record (EMR) system in an adult intensive care unit (ICU) setting. In order to assess the impact of smart infusion pump and EMR interoperability, we observed whether there were changes in the frequency of electronic medication administration record (eMAR) documentation of dose titrations in epinephrine and norepinephrine infusions in the ICU setting. As a secondary endpoint, we examined whether smart pump/EMR interoperability had any impact on the rate of alerts triggered by the dose-error reduction software. Pharmacist satisfaction was measured to determine the impact of smart pump/EMR interoperability on pharmacist workflow. In the preimplementation phase, there were a total of 2,503 administrations of epinephrine and norepinephrine; 13,299 rate changes were documented, for an average of 5.31 documented rate changes per administration. With smart pump interoperability, a total of 13,024 rate changes were documented in association with 1,401 administrations, for an average of 9.29 documented rate changes per administration (a 74.9% increase). A total of 1,526 dose alerts were triggered in association with 76,145 infusions in the preimplementation phase; there were 820 dose alerts associated with 48,758 autoprogammed infusions in the postimplementation phase (absolute difference, -0.32%). ICU pharmacists largely agreed (75% of survey respondents) that the technology provided incremental value in providing patient care. Interoperability between the smart pump and EMR systems proved beneficial in the administration and monitoring of continuous infusions in the ICU setting. Additionally, ICU pharmacists may be positively impacted by improved clinical data accuracy and operational efficiency.

Investigating multiple sources of data for smart infusion pump and electronic health record interoperability.

Infusion pump data, which describe compliance to dose-error reduction software among other metrics, are retrievable from infusion pump vendor software, electronic health record (EHR) systems, and regional and national data repositories such as the Regenstrief National Center for Medical Device Informatics (REMEDI). Smart infusion pump and EHR interoperability has added to the granularity and complexity of data collected, and clinicians are challenged with efficiently comprehending and interpreting the data and reports available. Collaborative partnerships between the Indianapolis Coalition for Patient Safety and the Regenstrief Center for Healthcare Engineering allowed for clinicians, informaticists, researchers, and engineers to compare the information gained and strengths of using smart infusion pumps, EHR, and REMEDI to assess hospital medication safety in a setting of interoperability. Seven reporting capabilities were used to compare available reports, and 2 hypothetical scenarios were developed to highlight these processes. Infusion pump vendor-provided software and reports were found to provide the most usable information for detailed infusion reporting, while the EHR was strongly usable for interoperability compliance and REMEDI excelled in benchmarking capabilities. While infusion analytics needs may differ across health systems, a better understanding of the strengths of infusion pump data and EHR data may help provide structure and direction in the infusion analytics process. Infusion data repositories such as REMEDI are useful tools to obtain information in a way not delivered by smart pump data.

Clinical and financial effects of smart pump–electronic medical record interoperability at a hospital in a regional health system

The pharmacist-led implementation of a smart pump-electronic medical record (EMR) interoperability program at a hospital within a regional health system is described. Smart pump-EMR interoperability involves a wireless, bidirectional connection by which infusion information transmitted by the EMR prepopulates infusion devices, reducing keystokes and opportunities for manual programming errors. The smart pumps transmit time-stamped infusion data to the EMR for nurse documentation. Use of interoperability technology forces the use of dose-error reduction software so that 100% of prepopulated infusions and dosage adjustments are protected. To improve i.v. medication safety and documentation at a 286-bed hospital within an 8-hospital health system, pharmacists led an initiative to implement smart pump-EMR interoperability as a first step toward systemwide implementation. The hospital's smart pump-EMR interoperability initiative resulted in patient safety and revenue-generation gains in the first 8 months after implementation. The mean number of keystrokes needed to program an infusion was reduced from 15 to 2 (an 86% decrease). Pump alerts, alert overrides, and reprogrammed or cancelled infusions were decreased. In addition, the program improved outpatient charge capture, resulting in $370,000 in incremental revenue. A pharmacist-led implementation of smart pump-EMR interoperability led to measurable, data-based improvements in i.v. medication safety and improved accuracy, timeliness, and efficiency of i.v. infusion documentation. Revenue was increased due to improved charge capture for outpatient i.v. infusions.

Using dose error reduction software in paediatrics to prevent medication error

AbstractBackgroundMedication errors during administration are not uncommon and have a higher risk and severity of error. Dose error reduction software (DERS) makes an infusion pump a ‘smart pump’.AimWe present our experience using DERS in an Australian paediatric hospital.DiscussionWe discuss adapting DERS for use in paediatrics: its limitations, and estimated preventable errors and cost avoidance. Importantly, DERS can prevent medication error in paediatrics.

Wireless Smart Infusion Pumps: A Descriptive Analysis of the Continuous Quality Improvement Data

Errors associated with the use of infusion pumps can cause serious harm or death in hospitalized patients and increased costs to the health care system. Our study reviewed the continuous quality improvement (CQI) data collected from a wireless smart infusion pump device implemented at one of the largest Canadian teaching hospitals. We reviewed the CQI summary data usage between February and December 2016 to assess dose error reduction software (DERS) compliance with the infusion pump’s master drug library and measure the frequency of monthly soft and hard limit events by clinical care area (CCA). In addition, we identified drugs that were most prone to alerts. The CQI data indicated that DERS compliance with the infusion pump ranged from 85.6 to 99.7% depending on the CCAs. The total number of soft limit double-confirmations was 35,174, and dexamethasone, oxytocin, and PACLitaxel had the highest frequency of double-confirmations. The total number of hard limits attempted observed was 13,188, and vancomycin, IV fluids, and potassium phosphate were more prone to hard limit alerts compared with other drugs during the study period. The study findings provided information on patterns of use and risk reduction opportunities to inform the hospital’s goal to enhance the delivery of quality care and patient safety. A CQI data analysis that incorporates open communication and detailed coordination in numerous departments across the hospital would help to increase the effectiveness of the new technology among the patient population.

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Intravenous (IV) drug administration, especially with 'smart pumps', is complex and susceptible to errors. Although errors can occur at any stage of the IV medication process, most errors occur during reconstitution and administration. Dose-error reduction software (DERS) loaded on to infusion pumps incorporates a drug library with predefined upper and lower drug dose limits and infusion rates, which can reduce IV infusion errors. Although this is an important advance for patient safety at the point of care, uptake is still relatively low. This article discuses the challenges and benefits of implementing DERS in clinical practice as experienced by three UK trusts.

Exploring the Current Landscape of Intravenous Infusion Practices and Errors (ECLIPSE): protocol for a mixed-methods observational study

IntroductionIntravenous medication is essential for many hospital inpatients. However, providing intravenous therapy is complex and errors are common. ‘Smart pumps’ incorporating dose error reduction software have been widely advocated to...

Infusion device standardisation and dose error reduction software

In 2004, the National Patient Safety Agency (NPSA) released a safety alert relating to the management and use of infusion devices in England and Wales. The alert called for the standardisation of infusion devices and a consideration of using centralised equipment systems to manage device storage. There has also been growing interest in smart-pump technology, such as dose error reduction software (DERS) as a way to reduce IV medication errors. However, questions remain about the progress that has been made towards infusion device standardisation and the adoption of DERS. In this article, the authors report the results of a survey investigating the extent to which the standardisation of infusion devices has occurred in the last 10 years and centralised equipment libraries are being used in practice, as well as the prevalence of DERS use within the UK. Findings indicate that while reported standardisation levels are high, use of centralised equipment libraries remains low, as does DERS usage.

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

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 weight-based medication programming. 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. 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%). 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.

Infusion device standardisation and dose error reduction software.

In 2004, the National Patient Safety Agency (NPSA) released a safety alert relating to the management and use of infusion devices in England and Wales. The alert called for the standardisation of infusion devices and a consideration of using centralised equipment systems to manage device storage. There has also been growing interest in smart-pump technology, such as dose error reduction software (DERS) as a way to reduce IV medication errors. However, questions remain about the progress that has been made towards infusion device standardisation and the adoption of DERS. In this article, the authors report the results of a survey investigating the extent to which the standardisation of infusion devices has occurred in the last 10 years and centralised equipment libraries are being used in practice, as well as the prevalence of DERS use within the UK. Findings indicate that while reported standardisation levels are high, use of centralised equipment libraries remains low, as does DERS usage.

Utilizing Electronic Health Record Information to Optimize Medication Infusion Devices: A Manual Data Integration Approach.

Health information technology is increasingly utilized within healthcare delivery systems today. Two examples of this type of technology include the capture of patient-specific information within an electronic health record and intravenous medication infusion devices equipped with dose error reduction software known as drug libraries. Automatic integration of these systems, termed intravenous (IV) interoperability, should serve as the goal toward which all healthcare systems work to maximize patient safety. For institutions lacking IV interoperability, we describe a manual approach of querying the electronic health record to incorporate medication administration information with data from infusion device software to optimize drug library settings. This approach serves to maximize utilization of available information to optimize medication safety provided by drug library software.