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MAKING SMART PUMPS SMARTER, MAKING IV THERAPY SAFER Much of this data is generated from Guardrails® soft


and hard limits. These safeguards are an integral part of the Guardrails®


Drug Library. Soft limits give


the clinician a warning whenever a programmed administration rate or total dose is above or below an accepted dose range. This limit can be overridden by the clinician, allowing for clinical judgement, but only after an advisory message has been given by the smart pump and acknowledged by the clinician. Hard limits apply to maximum doses above which the drug would be toxic or where patient harm is likely. Hard limits require the clinician to reprogram a safe dose. All soft and hard limit breaches are recorded by the pump. This fl agging up of near-miss events will be discussed later in the context of the CQI Reporter®


system.


Patient protection and dose limiting One study that took an 8-hour ‘snapshot’ of 426 IV infusions and IV medications given by pump found that 67% of them had one or more errors. Thirty seven of these were rate related and/or programming errors. One programming error was life-threatening (Husch et al, 2005).


Guardrails® drug library software, when used with Alaris®


smart pumps, supports the clinician in mitigating the risk of what has become known as ‘death by decimal point’. Rothschild et al (2005) described how one misplaced decimal point during pump programming could cause death and identifi ed cases where this error increased the dose of IV medication a patient receives by a factor of 10.


Thimbleby and Cairns (2010) identifi ed this ‘out by 10 error’ as being most commonly made by mis-keying a decimal point or a zero and also suggested that:


‘Ironically, the more skilled a user, the less attention they will pay to what ought to be routine outcomes, so the more likely these types of error will go unnoticed until they have untoward consequences’.


The Guardrails® hard limits described above are a check


on such ‘errors of automaticity’ by the user. Guardrails®


Contemporary IV therapy is highly complex and can be high risk by nature. Guardrails®


software can use up to hard limits are therefore set for every


continuous or intermittent drug. For example, having a hard limit of 1 mcg/kg/min for a noradrenaline infusion will prevent a clinician intending to program a therapeutic rate of 0.3 mcg/kg/min from inadvertently infusing 3 mcg/kg/min—a potentially lethal dosage level.


As briefl y discussed above, soft limits are designed to advise clinicians that their dose selection is of questionable therapeutic value. For example, an


30 profi les, with 100 drugs per profi le, which ensures that specifi c concentrations of drugs can be available for areas such as paediatric ICUs, where clinicians need to ensure effective drug delivery without unacceptable fl uid loads for differing patient weights. Guardrails®


also has


a facility for specifi c therapies that allows clinicians to mandate duration and specifi c dosing. This is particularly useful in oncology where drug dose and rate for the same medication may differ radically between regimens, and in anti-thrombotic therapy, where treatment for deep vein


BJN July 2013 CareFusion Supplement 23


intermittent infusion of vancomycin can carry a soft limit of 20 mg/kg/dose. Programmed doses of 30 mg/ kg (acceptable in severe infections) would be allowed by the pump, but only after the clinician has received a warning and has affi rmed their decision to continue. Setting soft limits is a balancing act between guiding clinicians towards best practice while not over- restricting clinician judgement.


This system brings the model of pharmacy-dispensed unit doses of medication to IV continuous infusions of titratable drugs. Taxis and Barber (2003) found that ‘most [IV drug] errors occurred when giving bolus doses or making up drugs that required multiple step preparation’ (i.e. errors of drug concentration). Guardrails®


limits bolus doses. It also controls maximum


and minimum concentrations and the duration over which a medication can be given. These limits help organisations mitigate the risk of problems such as ‘red- man syndrome’, a recognised complication of over-rapid infusion of vancomycin. Minimum soft limits can also guide clinicians away from sub-therapeutic doses.


Trbovich et al (2009) have suggested that institutions can use smart pumps to encourage a cultural shift among their nursing staff to programming only by dose and not by making conversions from dosage to rate by volume (i.e. mg/hour orders being converted at the bedside to ml/hour for administration). The Guardrails®


is the default setting for Alaris pumps, as recommended by the ECRI institute (2012), as this:


‘Encourage[s] the entry of dose rate, [which] reduces the need for error-prone mathematical conversions’ (Trbovich et al, 2009).


Much has been made of the ability of information being made available at the point of care to guide clinical judgement (Thompson, 2003). Guardrails®


drug library


is integrated into the delivery device and acts as a point-of-care drug guide.


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