Pump Programming Errors Research Articles

Impact of Computerized Orders for Pediatric Continuous Drug Infusions on Detecting Infusion Pump Programming Errors: A Simulated Study

Continuous infusion medications are associated with fatal adverse events in pediatric intensive care units. The effect of computerized orders on detecting infusion pumps programming errors has never been studied. Using a crossover design, we examined the effect of using computerized orders for continuous infusions as compared with that of using handwritten orders on nurse ability to detect infusion pump programming errors, time required to verify pump settings, and user satisfaction. The computerized orders saved nurses time but did not improve their ability to detect infusion pumps programming errors. Nurses preferred computerized orders. High error rate was related to manual calculations and inconsistent use of computerized orders.

Emerging treatment modalities: Balancing efficacy and safety

The advantages and disadvantages of intravenous patient-controlled analgesia (i.v. PCA) and epidural analgesia are discussed. New approaches to the management of patients with acute post-operative pain are described. The results of controlled clinical trials with these modalities are presented. Intravenous patient-controlled analgesia, while effective, is a burdensome technology requiring approximately 125 steps and at least 6 staff members. Furthermore, medication and pump programming errors may lead to patient injury. Epidural analgesia via catheter has a high reported failure rate, causing analgesic gaps and requiring a high level of staff intervention. In a clinical trial involving hip arthroplasty, extended-release epidural morphine demonstrated a 48-hour duration of action with a marked reduction in need for supplemental analgesia. The fentanyl Iontophoretic Transdermal System has demonstrated therapeutic equivalence with morphine intravenous patient-controlled analgesia and similar safety. Selective opioid antagonists are under development that may selectively block gastrointestinal opioid receptors while preserving analgesia. Recently approved agents and those in development may address a variety of unmet needs in the management of patients with post-operative pain.

Transdermal patient-controlled analgesia

Viscusi and Schechter1 provide a useful summary of various techniques of pain management using patient-controlled analgesia (PCA) delivered by different routes including epidural, i.v., and transdermal. Their analysis of the potential benefits of patient-activated transdermal analgesia system (PATS) delivery of fentanyl for PCA over other routes of administration suggests that this method may enhance effectiveness and minimize adverse respiratory events, particularly those associated with PCA pump-programming errors. We provide additional insight into these issues on the basis of our use of new technology that assesses continuous respiratory monitoring for patients receiving i.v. PCA with multiple opioid drugs. Since June 2004, we have used two respiratory monitoring devices to continuously measure arterial oxygen saturation and exhaled end-tidal carbon dioxide as part of an integrated, modular system of i.v. PCA delivery.a These devices have identified multiple patients who have experienced respiratory depression that might not have otherwise been detected before serious negative outcomes occurred.2,3 In addition, our analysis of continuous quality improvement (CQI) data from these devices indicates that respiratory depression in patients using PCA may be more common than is currently believed.4,–6

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology

Failure mode and effects analysis (FMEA) was used to evaluate a smart i.v. pump as it was implemented into a redesigned medication-use process. A multidisciplinary team conducted a FMEA to guide the implementation of a smart i.v. pump that was designed to prevent pump programming errors. The smart i.v. pump was equipped with a dose-error reduction system that included a pre-defined drug library in which dosage limits were set for each medication. Monitoring for potential failures and errors occurred for three months postimplementation of FMEA. Specific measures were used to determine the success of the actions that were implemented as a result of the FMEA. The FMEA process at the hospital identified key failure modes in the medication process with the use of the old and new pumps, and actions were taken to avoid errors and adverse events. I.V. pump software and hardware design changes were also recommended. Thirteen of the 18 failure modes reported in practice after pump implementation had been identified by the team. A beneficial outcome of FMEA was the development of a multidisciplinary team that provided the infrastructure for safe technology implementation and effective event investigation after implementation. With the continual updating of i.v. pump software and hardware after implementation, FMEA can be an important starting place for safe technology choice and implementation and can produce site experts to follow technology and process changes over time. FMEA was useful in identifying potential problems in the medication-use process with the implementation of new smart i.v. pumps. Monitoring for system failures and errors after implementation remains necessary.

Intrathecal baclofen in cerebral palsy movement disorders.

Intrathecal baclofen reduces spasticity in individuals with cerebral palsy. Intrathecal doses are far lower than oral doses and the effects are considerably greater, and the side effects are fewer. Response to intrathecal baclofen must be confirmed by a screening trial before implantation of a pump for chronic infusion. Intrathecal baclofen reduces spasticity in the upper and lower extremities and is often associated with improved gait and upper extremity function. Quality of life improves for patients and caregivers. The Medtronic pump has been exceedingly reliable and typically functions for 4 or 5 years. The currently available intrathecal catheter is associated with far fewer complications than the initial catheter. Baclofen overdoses are unusual and are usually caused by pump programming errors rather than pump malfunction. Preliminary studies suggest that continuous intrathecal baclofen infusion reduces generalized dystonia in cerebral palsy. Screening to determine response of dystonia to intrathecal baclofen is by continuous infusion. The doses required to reduce dystonia are higher than those for cerebral spasticity. Additional investigations are underway to quantify the effects of continuous intrathecal baclofen infusion on communication, disability, and dystonia.