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IMPLEMENTING AND EVALUATING DOSE ERROR REDUCTION SOFTWARE


majority of infusions (65.4%, 173 891) were found to have been started using the DERS settings (Table 1) with the minority of infusions (34.6%, 91 989) started in ml per hour with no DERS settings.


Some 3700 (1.4%) infusion starts caused a DERS alert to be displayed to the user. Of these, 831 (0.3%) were above the hard limit and 1331 (0.5%) above and 1538 (0.6%) below the soft limits. Display of 317 (8.6%) alerts resulted in the ‘error’ being corrected by reprogramming the infusion rate within set limits, 478 (12.9%) were cancelled and 2452 (66.3%) were overridden with the rate of infusion unchanged. For 453 (12.2%) the actions were not recorded by the infusion device software in a way that could be included in reports for analysis (Table 1).


Examining the hard limit over-infusion rate alerts, the majority (635, 76.4%) of these alerts involved over-infusion attempts by up to two and half times the agreed hard limit. However, 196 (23.6%) involved over-infusion attempts between 2.5 and 50 times the agreed hard limits (Table 2).


Infusion rates of 10–50 times the set hard limits included infusions of Actrapid®


insulin and potassium chloride


(Table 3). Other drug infusion attempts that prompted hard limit infusion alerts include amiodarone and heparin (Table 4), digoxin, gentamicin, phenytoin and oxytocin (Table 5).


Conclusion and discussion This report describes a successful implementation of electronic infusion devices with DERS in an NHS acute hospital Trust. The data show that clinical users employed DERS for the majority of infusion starts. This technology provides important additional electronic double checks to minimise the risk of death and serious harm from over- and under-infusion rates with drug solutions.


Over a 12-month period with normal safeguards in place, infusion rate alerts were displayed to clinical staff operating electronic infusion devices, resulting in changes or cancellations to the initial rate of administration selected.


Further refi nement of the DERS system is required. A high percentage of soft-limit alerts were overridden in practice. This raises the question of whether there is a need for soft limits to be used in the future. Hospitals


Table 2. Number and type of hard limit infusion rate alerts from DERS Type of hard limit infusion rate alerts Alerts 06/04/2010–06/10/2010 Alerts 28/12/2010–28/6/2011 Total % >1.0–1.5 >1.5–2.0 >2.0–2.5 >2.5–5.0 >5.0–10 >10–50


173 166 34 82 25 17


Total responses to DERS alerts 497


132 108 22 45 19 8


334


305 274 56


127 44 25


831


36.6 33.0 6.8


15.3 5.3 3.0


100


Table 3. Number and type of DERS infusion rate alerts 10–50 x greater than hard limits Infusion type


Actrapid insulin 50 units in 50 ml Potassium chloride 40 mmol in 100 ml Epoprostenol 500 micrograms in 50 ml Furosemide 250 mg in 50 ml Phenylephrine 10 mg in 50 ml Voluven


Sodium chloride 0.9% Gelofusin


Total 12 CareFusion Supplement BJN July 2013


Alerts 06/04/2010–06/10/2010 Alerts 28/12/2010–28/6/2011 13 0 0 2 1 0 0 1


3 2 1 0 0 1 1 0


17 8


Total 16 2 1 2 1 1 1 1


25


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