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Perspectives on Safety > Perspective
with commentary by Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN, Bar Coding for Medication Safety, September 2008
Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.
Journal Article > Commentary
Vanderveen T. Patient Saf Quality Healthc. January/February 2007.
The author discusses high-risk intravenous infusions, smart pump technologies that support safe delivery of medications, and effective use of smart pump data to inform improvements.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
Journal Article > Study
Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts.
Mansfield J, Jarrett S. Hosp Pharm. 2015;50:113-117.
Enhancing alarm management to decrease unnecessary alerts is a critical step in making decision support usable for health care professionals. This intervention study describes how inpatient pharmacists modified alerts on intravenous infusion pumps to reduce the number of clinically irrelevant alerts. A previous AHRQ WebM&M commentary describes consequences of overriding an important alert as a result of alarm fatigue.
Journal Article > Commentary
Carlson R, Johnson B, Ensign RH II. Am J Health Syst Pharm. 2015;72:777-779.
Although infusion pumps improve the safety of medication delivery, they can also contribute to alert fatigue and decrease individualized patient care. This commentary describes how a large health care system developed a scoring system to analyze the appropriateness of alerts recorded by infusion pumps and customize concentrations of the drugs delivered.
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
Smart pumps offer both benefits and drawbacks that can affect medication safety. This newsletter article explores missteps related to lack of compliance with setting hard stops to protect patients when using unique intravenous medication concentrations. Recommendations to prevent errors include using standardized dosing concentrations as often as possible, adhering to metric unit dosing requirements, and verifying pump programming settings.