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Approach to Improving Safety
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Search results for "United States of America"

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Journal Article > Commentary

Improving infusion pump safety through usability testing.

Miller KE, Arnold R, Capan M, et al. J Nurs Care Qual. 2017;32:141-149.

Usability testing is an important step toward safely integrating new technologies into medical practice. This commentary describes the testing processes used for an infusion pump integration initiative. The authors highlight the importance of proactively identifying and addressing potential failures when introducing new equipment.

Press Release/Announcement

Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.

Hazards in the magnetic resonance imaging environment can result in patient harm. This announcement raises awareness of inaccuracies and disruptions that may affect the safety of patients with implantable infusion devices who undergo an MRI exam. The statement recommends that patients inform their care team and carry an implant card with information about the implanted device to prevent these problems.

Journal Article > Commentary

Infusion medication error reduction by two-person verification: a quality improvement initiative.

Subramanyam R, Mahmoud M, Buck D, Varughese A. Pediatrics. 2016;138:e20154413.

Infusion pump programming is vulnerable to human error. This commentary describes how an improvement initiative tested a two-person verification strategy. Project leaders employed educational and feedback strategies along with plan-do-study-act cycles. The initiative resulted in reduced errors in pump programming and improvements in safety culture.

Journal Article > Commentary

Changing smart pump vendors: lessons learned.

Arthur KJ, Catlin AC, Quebe A, Washington A. Hosp Pharm. 2016;51:782-789.

Changes in processes, devices, and technologies can increase risk of human error. This commentary discusses how switching from one smart pump system to another can have unintended consequences and recommends tactics to prevent the problems associated with implementing new technology from reaching patients.

Web Resource > Government Resource

Interference between CT and Electronic Medical Devices.

Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration. April 12, 2016.

This website alerts clinicians and patients to risks for patient harm associated with implanted electronic medical devices, such as insulin infusion pump and pacemakers, when x-rays are used during CT examinations.

Journal Article > Study

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

Schnock KO, Dykes PC, Albert J, et al. BMJ Qual Saf. 2017;26:131-140.

Medication errors associated with intravenous smart pumps are a safety concern. Because errors are not always reported, the magnitude of this problem has been unknown. In this study, direct observation of nurses using smart pumps revealed that 60% of medication infusions involved one or more errors, but actual harm to patients was rare. The most common errors involved incorrect infusion rates and workarounds like bypassing the smart pump. These results accentuate a need for improvements in smart pump design to enhance safety and usability. A previous WebM&M commentary describes consequences of an incorrect medication infusion.

Newspaper/Magazine Article

Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1.

ISMP Medication Safety Alert! Acute Care Edition. November 19, 2015;20:1-5.

Infusion therapies are increasingly being administered at home through the use of ambulatory pump devices. This article reports results from hospital surveys regarding how they manage patients using three categories of ambulatory infusion pumps to ensure that therapy is safely continued or stopped. The data revealed weaknesses in planning, clinician education, and standardization of processes.

Journal Article > Commentary

Maximizing smart pump technology to enhance patient safety.

Makic MBF. Clin Nurs Spec. 2015;29:195-197.

Smart pumps are considered a valuable method to improve medication safety. However, users may engage in workarounds that bypass the safety features of the equipment. This commentary relates risks and benefits associated with smart pumps and highlights opportunities to augment adoption and use of smart pump technology to prevent medication errors. A past AHRQ WebM&M perspective describes the value of smart pump technologies as a medication safety strategy.

Journal Article > Commentary

Development of an "infusion pump safety score".

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.

Journal Article > Organizational Policy/Guidelines

Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group.

Heinemann L, Fleming GA, Petrie JR, Holl RW, Bergenstal RM, Peters AL. Diabetes Care. 2015;38:716-722.

Insulin is a high-alert medication that can lead to harm if incorrectly administered. Insulin pump problems can be caused by human, mechanical, or drug stability failures. This policy statement describes ways to use adverse event data, manufacturer information, and technical specifications to enhance the safety of insulin therapy.

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 > Review

Benefits and risks of using smart pumps to reduce medication error rates: a systematic review.

Ohashi K, Dalleur O, Dykes PC, Bates DW. Drug Saf. 2014;37:1011-1020.

Smart infusion pumps, which contain pre-programmed libraries with standardized dosing for commonly used intravenous medications, are considered an integral component of efforts to prevent medication errors. This systematic review found evidence that smart pumps can effectively prevent medication administration errors and clinical adverse drug events. However, the authors uncovered problems associated with smart pump implementation as well, including alert fatigue and failure of clinicians to use the system as intended. In particular, as discussed in a recent qualitative study, nurses frequently employ workarounds that may bypass some safety features of smart pumps. The role of smart pumps in medication safety was discussed in more detail in an AHRQ WebM&M perspective.

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.

Journal Article > Study

The mixed blessings of smart infusion devices and health care IT.

Nemeth CP, Brown J, Crandall B, Fallon C. Mil Med. 2014;179(suppl 8):4-10.

This study provides a detailed description of the overlapping technological, organizational, and human factors associated with the use of smart pumps and includes insights into potential pitfalls that may pose patient safety threats. The authors make specific recommendations to improve the real-world use of smart pump technology.

Journal Article > Commentary

Systems approach and systems engineering applied to health care: improving patient safety and health care delivery.

Ravitz AD, Sapirstein A, Pham JC, Doyle PA. Johns Hopkins APL Tech Dig. 2013;31:354-365.

This commentary describes a systems engineering approach to understanding how interactions between people, processes, and technology can affect infusion pump usability in intensive care units.

Journal Article > Study

A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.

Tran M, Ciarkowski S, Wagner D, Stevenson JG. Jt Comm J Qual Patient Saf. 2012;38:112-119.

After adverse events occurred due to incorrect dosing of patient-controlled analgesia, implementation of smart infusion pumps resulted in a significant decrease in potential medication errors.

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

Enhancing patient safety with intelligent intravenous infusion devices: experience in a specialty cardiac hospital.

Wood JL, Burnette JS. Heart Lung. 2012;41:173-176.

Implementation of smart intravenous pumps was associated with fewer adverse events and considerable cost savings at an academic medical center.

Journal Article > Commentary

Smart pumps: implications for nurse leaders.

Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.

This commentary discusses the benefits and limitations of relying on smart pumps to improve medication safety.

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.

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