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IMPLEMENTING AND EVALUATING DOSE ERROR REDUCTION SOFTWARE


should have the option to switch soft limits on or off, depending on the perceived benefi ts to patient safety. Further software improvements are required to ensure that all responses to DERS alerts are recorded in a way that can be included in reports. The method of collecting DERS alert data and reprogramming infusion devices’ DERS should also be streamlined. This may include using wireless communication instead of requiring manual connection to each individual device.


Automated data processing and report production in the hospital is also essential. These improvements will enable the governance team within the hospital to interrogate the DERS alert data and enable reports to be produced, analysed and acted on when required.


A recognised limitation of DERS technology is that the identity of the individuals who programmed the infusion device resulting in a DERS alert is not recorded.


Table 4. Number and type of DERS infusion rate alerts 5–10 x greater than hard limits Infusion type Blood


Gentamicin


Actrapid insulin 50 units in 50 ml Omeprazole main 80 mg in 250 ml Amiodarone 900 mg in 500 ml Heparin 50 000 units in 50 ml Sodium bicarbonate 8.4% Tirofi ban 12.5 mg in 250 ml Other infusions


Total


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


14 0 0 0 1 0 9


25


2 1 6 2 5 2 0 1 0


19


Table 5. Number and type of infusion rate alerts 1.5–5 x greater than hard limits Infusion type Blood


Insulin Actrapid 50 units in 50 ml Gentamicin Digoxin


Potassium chloride 40 mmol in 100ml saline Potassium chloride 40 mmol in 500ml saline Potassium chloride 40 mml in 1L saline


Potassium chloride 40 mmol in 1L dextrose 5% Potassium chloride 40 mmol in 1L dextrose/saline Phenytoin loading dose Insulin/dextrose Oxytocin


Bupivicaine


Sodium bicarbonate 8.4% Amiodarone Vancomycin


Other infusions Total


15 24 15 27 11 8 2 0


14 8 2 0


37 3 6


285 457


27 0


11 13 7


10 9 3 2


11 5 4 1 2 0 0


177 19


20 2 5 2 1 1 9


44


Total 2 2


Alerts 06/04/2010–06/10/2010 Alerts 28/12/2010– 28/6/2011 Total 0


27 15 35 28 34 21 17 5 2


25 13 6 1


39 3 6


462 739


BJN July 2013 CareFusion Supplement 13


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