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Smart pumps are not smart on their own

From the April 19, 2007 issue

Infusion-related medication errors expose patients to a high risk of harm. Smart infusion pumps with dose-checking technology are available to help avert these potentially harmful errors. The role of the smart pump is to "remember" the large number of "rules" (hospital-defined dosing limits and other clinical advisories) entered into the drug library, and to apply those "rules" during pump programming to warn clinicians about potential unsafe drug therapy.(1) Equally important, the role of the clinician is to USE the technology consistently. As with other technologies, clinicians have sometimes bypassed its use, only to realize its true value after a serious error has occurred that could have been prevented with the technology. The following describes one such instance.

A 19-year-old obese woman who had recently undergone C-section delivery of a baby presented in the emergency department (ED) with dyspnea. Believing the patient had developed a pulmonary embolism, the physician prescribed an IV heparin bolus dose of 5,000 units followed by a heparin infusion at 1,000 units/hour. After administering the bolus dose, a nurse started the heparin infusion but misprogrammed the pump to run at 1,000 mL/hour, not 1,000 units/hour (20 mL/hour). By the time the error was discovered, the patient had received more than 17,000 units (5,000 unit loading dose and about 12,000 units from the infusion) in less than an hour since arrival in the ED. A smart pump with dosing limits for heparin had been used. Thus, the programming error should have been recognized before the infusion was started. However, the nurse had elected to bypass the dose-checking technology and had used the pump in its standard mode. It was quite fortunate that the patient did not experience adverse bleeding, as her aPTT values were as prolonged as 240 seconds when initially measured and 148 seconds two hours later. 

Further investigation of this event uncovered that, like the nurse involved in this error, most nurses in this hospital were bypassing the dose-checking technology available with the smart pumps! Although the reasons for not using the technology were not specified in this error report, studies about smart pump implementation have provided some familiar answers about why clinicians have chosen to bypass the dose-checking technology: falsely low perceptions of risk, failure to make adjustments in the drug library when alerts are not credible, extra work to use the technology, time pressures, clinical emergencies, and a culture that inadvertently supports at-risk behaviors, including technology work arounds.(1-4) Smart pumps that turn on in a standard mode (no dose-checking), or default to a standard mode, can also discourage compliance as it takes extra effort to switch the pump to the dose-checking mode and to access the library. Smart pumps that require extra effort to work in the standard mode are more desirable, as humans can always defeat technology if it is perceived to be a barrier.(4) 

Healthcare providers can compare smart pump technology to a seatbelt. Unlike airbags, which are safety features that are not optional and not subject to being bypassed by the user, seatbelts are an optional safety feature. They can be bypassed, just like dose-checking technology, despite a policy that may requires its use. Thus, it is not enough to purchase smart pumps, program the library to enable the technology, distribute the pumps, educate users, and hope that the dose-checking feature will always be used. A culture of safety must exist that drives clinicians to avoid bypassing such a safety feature, or to report conditions that encourage work-arounds so they can be remedied. See Table 1 (page 1 of the PDF version of the newsletter and below) for a definition of a safety culture. A culture of safety also promotes the critical thinking necessary to evaluate pump alerts from both a clinical and safety perspective, significantly limiting overrides to situations that have been fully appraised. Thus, a culture of safety is foundational to both compliance with using the smart pump technology as well as heeding the alerts that may arise. Additional measures that can nurture compliance with smart pump technology and attention to the alerts include: analyzing pump logs and making necessary adjustments to the drug library (see Table 2 in the PDF version of the newsletter and below for an example); evaluating all overrides; publicizing "good catches;" and conducting focus groups and satisfaction surveys to solicit nursing feedback. 

Healthcare clinicians should not view the dose-checking feature of smart pumps as an option that can be turned on or off. Nor should the alerts that arise from the system be bypassed without serious consideration. Compliance with the technology should be measured and any barriers should be identified and removed. Much like other technologies, part of the planning process for smart pumps should include a readiness assessment with particular attention to the organizational culture. For every error like the one described above, there are many more that have been prevented because smart pump technology has been employed. There is little doubt that smart pumps can save lives if properly designed AND used. In fact, in the not too distant future, failure to use technology like this will likely be considered suboptimal care.

Please visit www.ismp.org/educational/teleconferences.asp for information about an ISMP teleconference series on smart pumps. On June 6, the program will focus on errors associated with standard pumps, the technology behind smart pumps, and tips on smart pump selection. On June 21, the program will feature the experiences of two clinicians from hospitals that have successfully employed smart pumps.

Table 1. Definitions of a safety culture*
Safety culture is the enduring value and priority placed on worker and public safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety, act to preserve, enhance and communicate safety concerns, strive to actively learn, adapt, and modify (both individual and organizational) behavior based on lessons learned from mistakes, and be rewarded in a manner consistent with these values.
*Source: Federal Aviation Administration Report 2002(5)

Table 2. An example of a drug library adjustment
A pharmacist at a mid-sized hospital pro-vided the following example of a necessary drug library adjustment recognized during analysis of alerts and nursing feedback.

During the first 4 months of using smart pumps, more than 600 error messages were generated for cefazolin. Investigation revealed that, while the IV label stated to give the drug over 30 minutes, the drug library had been programmed to infuse the drug over 1 hour or more. The 600 error messages comprised 13% of all alerts, and about 66% of all alerts when evaluating the top ten drugs for which alerts occurred. Nurses also reported the problem, noting that the error messages for cefazolin did not make sense and, thus, reduced the credibility of the alert system. Compliance with using the dose-checking technology continues to improve as necessary changes in the drug library are identified and made.

References: 1) Keohane CA, Hayes J, Saniuk C, et al. Intravenous medication safety and smart infusion systems. J of Infusion Nursing 2005; 28(5):321-28. 2) Fields M, Peterman J. Intravenous medication safety system averts high-risk medication errors and provides actionable data. Nursing Admin Quarterly 2005; 29(1):78-87. 3) Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Critical Care Medicine 2005; 33(3):533-540. 4) Leape LL. "Smart" pumps: a cautionary tale of human factors engineering. Critical Care Medicine 2005; 33(3):679-680. 5) Weigmann DA, Zhang H, von Thaden TL, et al. A synthesis of safety culture and safety climate research. Technical Report ARL-01-3/FAA-02-2, June 2002. Prepared for the Federal Aviation Administration. Contract DTFA 01-G-015.
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