"Smart" infusion pumps
join CPOE and bar coding as important ways to prevent medication
From the February 7, 2002 issue
Computerized prescriber order entry (CPOE) and bar code applications
for drug dispensing and administration represent technologies
that are capable of reducing medication errors. Unfortunately,
most hospitals have not yet implemented these systems, so
many errors that otherwise might be eliminated continue to
put patients at risk. Yet, even if these technologies were
fully installed, serious errors are still possible, especially
with IV "high alert" medications. Even if the right
drug and dose are at hand, a misprogrammed infusion pump can
leave a patient only a button press away from disaster.
A new technology has emerged and already it's beginning to
play a role in risk reduction. Infusion systems, such as those
from Alaris Medical Systems (MEDLEY) and Baxter Healthcare
Corporation (COLLEAGUE CX), allow hospitals to enter
various drug infusion protocols into a drug library with pre-defined
dose limits. If a dose is programmed outside of established
limits or clinical parameters, the pumps halt or provide an
alarm, informing the clinician that the dose is outside the
recommended range. Some pumps have the capability of integrating
patient monitoring and other patient parameters such as age
or clinical condition. Other manufacturers are bringing similar
devices to market.
Recently, a physician in the emergency department wrote an
order for INTEGRILIN (eptifibatide) but inadvertently
prescribed a dose appropriate for REOPRO (abciximab).
The Integrilin infusion was initiated and continued for approximately
36 hours after the patient was transferred to a medical/surgical
unit. During this time, the patient's mental status was deteriorating.
At this point, the hospital was switching to the Alaris Medley
system which performs a "test of reasonableness"
before allowing the infusion to begin. As the nurse was transferring
the infusion parameters from the old infusion system to this
new system, safety software incorporated in the device alerted
the nurse that there was a "dose out of range."
The pump would not allow the nurse to continue until a pharmacist
was called and the mistake was corrected. In another case,
a hospital's heparin protocol called for a loading dose of
4,000 units followed by a constant infusion of 900 units/hour.
The loading dose was administered correctly, but the nurse
inadvertently programmed the continuous dose as 4,000 units/hour.
Since the pump limit for heparin as a continuous infusion
was set at 2,000 units/hour, the infusion device would not
start until the dose was corrected.
In both of the above cases, and in many others discussed
in the ISMP Medication Safety Alert!, these mistakes
may have gone undetected without preprogrammed limits. For
example, we recently received a report where a nurse attempted
to program an infusion pump for a baby receiving TPN by inputting
13.0 mL/hour. The decimal point key on the pump was somewhat
worn and difficult to engage. Without realizing it, the nurse
programmed a rate of 130 mL/hour. Fortunately, the error was
discovered within one hour. The baby's glucose rose to 363,
so the rate of infusion for the TPN was decreased for a while
and the baby was fine. A "smart" pump, programmed
with patient and drug parameters, would have been able to
recognize the error before the infusion even began.
Clinical trials will be underway soon to quantify the value
of these infusion systems in reducing medication error rates.
They seem to hold great promise. With CPOE, bar coding and
"smart" infusion pumps, we may finally have a solid
defense against the most serious medication errors.