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Approach to Improving Safety
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Search results for "Active Errors"

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Journal Article > Commentary

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

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Newspaper/Magazine Article

Selection of incorrect medication pump leads to chemotherapy overdose.

ISMP Canada. August 26, 2015;15:1-4.

Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. In response to an incident involving a chemotherapy administration error as a result of utilizing the incorrect infusion pump, this newsletter article discusses the development of a point-of-care checklist to assist in use of infusion pumps to improve safety.

Journal Article > Study

Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.

Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2014 Aug 12; [Epub ahead of print].

Smart infusion pumps, which provide alerts and decision support for high-risk medications, have a proven record of preventing adverse drug events. However, like with all technology users may engage in workarounds that (intentionally or inadvertently) bypass the safety features of the equipment. This qualitative study among nurses at three health systems identified several reasons why nurses used workarounds despite having an overall strong positive perception of smart pumps. While the technology itself necessitated workarounds at times (for example, if the drug to be infused was not in the pump's programmed library), workarounds were more commonly attributed to nontechnical factors such as production pressures or inadequate training. In order to improve adherence to smart pump's safety features, organizations will need to address both technical factors and issues related to nurses' work environment.

Newspaper/Magazine Article

Smart pump custom concentrations without hard "low concentration" alerts.

ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.

This newsletter piece reviews smart infusion pump errors and makes recommendations to prevent them.

Journal Article > Study

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

Patient-controlled analgesia (PCA) is generally quite safe, but prior studies have shown that errors associated with PCA frequently result in patient harm. Due to several critical incidents associated with PCA errors, this Canadian hospital system implemented a multifaceted safety program including use of smart infusion pumps, standardized order sets, and mandatory error reporting. These interventions resulted in a significant reduction in PCA errors, chiefly by reducing pump programming errors (the most common type of error before the intervention). A PCA error with devastating clinical consequences is discussed in an AHRQ WebM&M commentary.

Journal Article > Study

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

Errors at the administration stage are common for intravenous medications. Programmable or smart infusion pumps are widely used as a means of preventing such errors. However, prior studies have found that smart pumps alone may not significantly reduce errors, as they do not eliminate wrong-patient errors and may be prone to workarounds. This study compared three types of pumps—traditional pumps, smart pumps, and smart pumps combined with bar-code technology—in a simulated inpatient unit. The results indicate that smart pumps may reduce administration errors when combined with bar-coding or when only "hard" (unchangeable) dosing limits are used. Ultimately, creation of a "closed-loop" system that integrates technological solutions to prescription and administration errors represents the optimal solution for eliminating medication errors.

Newspaper/Magazine Article

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

ISMP Medication Safety Alert! April 8, 2010;15:1-3.

Detailing a recent lethal overdose of heparin, this piece describes common risks and offers suggestions to improve the safety of heparin administration.

Journal Article > Study

Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety.

Porat N, Bitan Y, Shefi D, Donchin Y, Rozenbaum H. Qual Saf Health Care. 2009;18:505-509.

Specific labels for high-risk intravenous medications successfully reduced medication errors and allowed nurses to identify medications more efficiently.

Journal Article > Study

Impact of computerized orders for pediatric continuous drug infusions on detecting infusion pump programming errors: a simulated study.

Sowan AK, Gaffoor MI, Soeken K, Johantgen ME, Vaidya VU. J Pediatr Nurs. 2010;25:108-118.

This study discovered that computerized provider order entry saved nurses time but did not improve their ability to detect infusion pump programming errors compared with handwritten orders.

Journal Article > Study

The rate and costs attributable to intravenous patient-controlled analgesia errors.

Meissner B, Nelson W, Hicks R, Sikirica V, Gagne J, Schein J. Hosp Pharm. 2009;44:312–324.

Medication errors associated with patient-controlled analgesia (PCA) are common and costly, according to this analysis of MEDMARX data. An AHRQ WebM&M commentary discusses a serious adverse drug event in a postoperative patient receiving PCA.

Cases & Commentaries

Are Two Insulin Pumps Better Than One?

  • Web M&M

Curtiss B. Cook, MD; January 2009

Admitted to the hospital for surgery, a man with type 1 diabetes mellitus asked the staff to leave his home insulin pump in place but did not mention that he was adjusting his insulin pump himself based on serial glucose measurements. As the patient was also receiving an intravenous insulin infusion, he developed hypoglycemia.

Newspaper/Magazine Article

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.

Newspaper/Magazine Article

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

This article describes dosing errors associated with improper concentration programming of patient controlled analgesia (PCA) pumps and provides recommendations for preventing future errors.

Newspaper/Magazine Article

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

This article reports on an overdose caused by improper label placement on a patient controlled analgesia (PCA) pump and provides recommendations for preventing pump-related medication errors.

Journal Article > Study

Using snowball sampling method with nurses to understand medication administration errors.

Sheu SJ, Wei IL, Chen CH, Yu S, Tang FI. J Clin Nurs. 2009;18:559-569.

This study used snowball sampling (in which focus group members recruit additional participants) to examine the self-reported incidence of medication errors among nurses in Taiwan.

Book/Report

Fluorouracil Incident Root Cause Analysis Report.

Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.

This report shares findings from a root cause analysis of a medication error incident that led to a patient's death. The report discusses systems failures that contributed to the event, as well as recommendations to improve safety.

Journal Article > Commentary

New technology, new errors: how to prime an upgrade of an insulin infusion pump.

Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.

The authors share a case report of errors associated with the introduction of new equipment in an ambulatory setting and discuss the importance of device selection and user training to minimize these failures.

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