Recently, ECRI Institute issued its top 10 list of health technology hazards, or problems that can result from using certain types of medical technologies.
These hazards reflect use errors that have been shown to be repeated by clinicians, and that ECRI experts have determined to be the most prevalent. Medication administration errors using infusion pumps are toward the top of the list.
The top 10 hazards on ECRI’s list include:
1. alarm hazards
2. infusion pumps
3. diagnostic radiology procedures
4. EHRs systems
5. interoperability failures
6. air embolisms
7. using adult technologies with pediatric patients
8. cross contamination of instruments
9. mobile device distractions
10. surgical fires.
Smart Infusion Pumps
With the advent of smart infusion pumps in the last decade, nurses are able to employ more advanced technology to manage medication administration.
The increasingly sophisticated devices feature drug libraries, or databases that hold the drug dosing information, including dosing limits, infusion parameters and drug specific advisories. Integrated software can calculate specific dose and delivery rates.
Many smart infusion pumps are able to integrate with electronic health records, and some even have become network devices, connecting to wireless networks in hospitals.
While smart pumps can help reduce medication errors and prevent patient injury, nurses must continue to follow standard safety precautions.
Remember the “five rights” of medication administration: the right patient, the right drug, the right dose, the right route, and the right time.1
The next step in infusion safety, according to ECRI’s recommendations, will involve integrating infusion pumps with electronic ordering, administration and documentation systems, and fostering a shift in mindset from viewing infusion pumps as stand-alone devices to viewing them as components of an integrated medication delivery system.
Following these protocols from the FDA may help prevent infusion pump errors:2
- Before starting an infusion or changing an infusion setting, confirm that the infusion pump is programmed correctly.
- When infusing a high-risk medication, have a second clinician perform an independent double check of infusion pump settings according to your facility’s policy.
- If the infusion pumps at your facility contain a drug library feature, use it according to facility policy.
- When a patient is receiving multiple infusions, consider labeling the infusion pump channels and corresponding tubing with the name of the medication or fluid to avoid programming the wrong channel or infusion pump.
- Don’t rely solely on the pump to identify problems. Monitor the patient and infusion according to nursing best practices and your facility’s policies and procedures.
- Pay attention to displayed alerts and cautions, and investigate them appropriately.
- When multidisciplinary teams are tasked with implementing and revising smart pump technologies and drug libraries, these teams should include members of each discipline that interfaces with the device.
- Continuously reevaluate drug library settings and modify them to align with the standard of care and facility policies and procedures. This should include implementing and altering soft and hard limits (when clinically relevant) as well as standardizing concentrations, dosing configurations, and names of high-risk medications throughout your institution.
- Make sure you’re properly educated to manage all infusion pumps used on your unit.
- Facility policies and procedures should be readily available, and clinicians should be promptly notified of changes or updates.
All healthcare facilities should be prepared to manage any type of workplace hazard by:3
- making technology-related safety an organizational priority
- ensuring that all clinical staff are qualified (trained, licensed or certified) for the equipment and treatments offered
- establishing a mechanism for identifying and responding to technology-related hazard notices and other safety problems for the devices in the facility’s inventory.
In addition, a well-prepared facility should have an organization-wide adverse event reporting system for device problems and incidents, in which:3
- Staff members are encouraged to report all events, including near misses, to the facility’s adverse event reporting system. Consistent with the ideals of establishing a culture of safety, the reporting system should take a nonpunitive approach, encouraging reporting to help identify problems, work toward their resolution, and facilitate learning.
- A standard procedure has been instituted to assess reported events (including near misses), and criteria have been established for determining when events require further analysis.
- Trends of errors are examined to identify issues that might require increased awareness, process or technology changes, or other forms of remediation.
- Relevant events are reported to the manufacturer and to the appropriate regulatory agency (FDA).
If you suspect a problem with an infusion pump, you can file a report on the FDA’s website: www.fda.gov/infusionpumps
References for this article can be accessed here.
Elizabeth Rosto Sitko
is managing editor of ADVANCE. Contact: firstname.lastname@example.org.