Smart Medication Delivery Systems

Issue
Medication errors are the most significant cause of medical injuries, representing 19.4% of all adverse events¹.  Intravenous (IV) infusions have been identified as frequent contributors to medication errors, and the injuries that result from them^{2, 3, 4}.  In an attempt to reduce infusion errors, manufacturers have developed pumps that have Dose Error Reduction Systems (DERS), which include hospital-defined drug libraries with dosing limits and other clinical advisories integrated into the system (i.e., smart pumps). Smart pumps, particularly those with bar code readers, are assumed to simplify aspects of the drug administration process. However, smart infusion systems (with or without bar coding) may add to the demands of the overall drug administration process or, in some cases, introduce completely new tasks (e.g., select the clinical care area, select drug name and concentration, or scan bar code on iv label) that may cause nurses to make new types of errors (e.g., select the incorrect drug concentration).

The Healthcare Human Factors Group collaborated with the Ontario Health Technology Advisory Committee (OHTAC) and the Medical Advisory Secretariat, Ministry of Health and Long-term Care, to evaluate new infusion pump systems, and provide recommendations regarding their implementation in Ontario. Of particular interest are the end-to-end issues associated with intravenous medication delivery, the key factors that contribute to their successful adoption and the intrinsic performance and usability of the smart pumps themselves.

Methods
The study combined high fidelity usability analysis of smart pumps in the labs at the Centre for Global eHealth Innovation, along with field studies to understand their impact on nurses’ performance and key factors that contribute to the successful migration from traditional pumps to smart pumps.

Results
As a patient safety initiative, effective use of smart pump technology is dependent not only on the design of the pump itself but also on the way it is implemented at the institution. Most healthcare facilities that are migrating from traditional pumps to smart pump systems are unaware of the need for a different implementation process, and therefore, are failing to deploy an integrated system.  Other key findings include:

• Thirteen percent of Ontario hospitals currently use smart pumps and another 6% are in the process of implementing smart pumps. Thus, adoption rate of smart large volumetric infusion pumps in Ontario has been low.
• Sixty-eight percent of Ontario hospitals that were interviewed did not ensure wireless connectivity prior to implementing smart pumps.
• Twenty-three percent of Ontario hospitals that were interviewed proceeded with their smart pump implementation, without establishing a complete list of standardized concentrations. Standardization of drug concentrations, however, is critical to ensuring (a) synchronicity between physician orders and smart pumps, and (b) compliance with use of the Dose Error Reduction System (DERS).
• Soft limits (that can be overridden) in smart infusion pumps had no significant effect in preventing errors. Sixty-seven percent of Ontario smart pump users that were interviewed reported having a high rate of soft limit overrides. That is, most institutions reported that nurses often ignore and override soft limit alerts.
• Hard (unchangeable) limits prevented dosing errors, thereby increasing patient safety. When faced with hard limit warnings, which do not allow nurses to override but rather force the re-programming of the pump setting, nurses do indeed respond in a safe manner. However, most Ontario smart pump users (i.e., 62%) that were interviewed do not implement hard limits, or only implement a few.
• Until barcode pumps are integrated with other systems within the medication administration process, their role in enhancing patient safety will be limited. Bar code pumps are susceptible to many of the same errors (e.g., wrong drug errors) as other types of pumps.

Smart Medication Delivery Systems Full Report
Date of issue: June 2009

OHTAC Recommendations
Date of issue: July 2009

References

1. Leape LL, Brennan TA, Laird NM, et al. (1991). The nature of adverse events in hospitalized patients: results from the Harvard Medical Practice Study II. NEngl J Med;324:377-84.
2. Kinnealey E, Fishman G, Sims N, et al. (2003). Infusion pumps with “drug libraries” at the point of care- a common solution for safer drug delivery. http:// www.npsf.org/download/Kinnealy.pdf (accessed 22 Dec 2008).
3. Ross LM, Wallace J, Paton JY. (2001). Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child;83(6):492– 497.
4. Kaushal R, Bates DW, Landrigan C, et al. (2001) Medication Errors and Adverse Drug Events in Pediatric Inpatients. JAMA; 285:2114-20.