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IMPLEMENTING AND EVALUATING DOSE ERROR REDUCTION SOFTWARE


In addition, infusion devices with DERS technology may be used in more than one clinical area and this makes it more diffi cult to provide additional support to areas and individuals generating DERS alarms.


Effective implementation of this new patient safety technology required effective leadership, multidisciplinary team work, clinical agreement to standardise infusion concentrations, a comprehensive training programme and an audit programme to indicate the effectiveness of the new technology in practice. There is a requirement for ongoing oversight of the DERS infusion device initiative by the multidisciplinary team as part of the Trust’s clinical governance structures.


Implementation of this technology has enabled infusion rate errors involving drug infusions such asconcentrated potassium chloride, insulin, phenytoin and digoxin to be avoided. These types of infusion errors could also be avoided in other NHS Trusts if DERS were used.


References Cousins DH (2013) Personal communications from infusion device manufacturers


Daily Mail (2011) Mother-of-four dies after blundering nurse administers TEN times drug overdose. Available at: www.dailymail.co.uk/health/article-1359778/ Mother-dies-nurse-administers-TEN-times-prescribed-drug.html


Daily Telegraph (2010) Baby dies after doctors’ neglect contributes to ‘massive overdose’. Available at http://www.telegraph.co.uk/health/ healthnews/7852722/Baby-dies-after-doctors-neglect-contributes-to-massive- overdose.html


Kastrup M, Balzer F, Volk T, Spies C (2012) Analysis of event logs from syringe pumps; a retrospective pilot study to assess possible effects of syringe pumps on safety in a university hospital critical care unit in Germany. Drug Saf 35(7): 563–74


Lee PT, Thompson F, Thimbleby H (2012) Analysis of infusion pump error logs and their signifi cance for health care. Br J Nurs 21(8): S12–20


Manrique-Rodríguez S, Sánchez-Galindo A, Fernández-Llamazares CM et al (2011) Smart pump alerts: all that glitters is not gold. Int J Med Inform 81(5): 344–50


Murdoch LJ, Cameron VL (2008) Smart infusion technology: a minimum safety standard for intensive care? Br J Nurs 17(10): 630–6


› Further software improvements are required to ensure that all responses to DERS alerts are recorded in a way that can be included in reports. ‹


National Patient Safety Agency (2007) Patient Safety Alert 20. Promoting safer use of injectable medicines. National Patient Safety Agency, London. Available at: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59812


National Patient Safety Agency (2010a) Design for Patient Safety. A Guide to the Design of Electronic Infusion Devices. National Patient Safety Agency, London. Available at: http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource. axd?AssetID=68536 (accessed 27.06.2013)


National Patient Safety Agency (2010b). Preventing Fatalities from Medication Loading Doses. Rapid Response Report 18. National Patient Safety Agency, London. Available at: http://www.nrls.npsa.nhs.uk/alerts/?entryid45=92305 (accessed 27.06.2013)


NHS Purchasing and Supply Agency (2008) Dose Error Reduction Systems for Infusion Pumps: CEP 08034. NHS Purchasing and Supply Agency, London. Available at: http://nhscep.useconnect.co.uk/CEPProducts/Catalogue.aspx (accessed 27.06.2013)


Pedersen CA, Schneider PJ, Scheckelhoff DJ (2012) ASHP national survey of pharmacy practice in hospital settings: dispensing and administration – 2011. Am J Health Syst Pharm 69(9): 768–85


Quinn C (2011) Smart practice: the introduction of a dose error reduction system. Br J Nurs 20(8 Suppl): S20–5


Upton D (2012) Supporting the implementation of smart pumps with DERS. Hospital Pharmacy Europe (63): 49–53.


14 CareFusion Supplement BJN July 2013


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