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Whether via a large volume pump or syringe pump, the design and capability of these devices has meant that signifi cant overdoses have gone largely undetected. Pumps have historically lacked safety checking systems and had no ability to recognise that a programmed infusion rate for a given drug was in excess of the recommended safe maximum and may lead to harm to the patient. Basically, the devices would deliver whatever infusion rate was programmed by the user, irrespective of the potency of the drug being administered.

Error in placement of decimal points and zeros via the pump keypad has been a particular problem and led to the well-publicised ‘death by decimal’ cases in the USA in the 1990s. The publicity generated by these fatalities resulted in calls for the infusion-devices industry to take positive action. The industry’s response was through much improved design for safety and the development of smart pump technology towards the end of the decade.

What makes a pump ‘smart’? DERS The term smart pump was originally coined by the Institute for Safe Medication Practices in the USA to describe an infusion pump with an inbuilt drug library that contains correct parameters for all the medications to be delivered by the pump. These safety software packages have now been available from the major infusion device manufacturers for nearly a decade. After initial experience in the home market was gained by the US manufacturers, the fi rst system was launched in Europe in 2003, with others following quickly. A review published in 2004 compared the features of the systems then available in the UK (Medicines and Healthcare products Regulatory Agency, 2004).

DERS provides a fi nal ‘test of reasonableness’ that can prevent an incorrect dose from accidentally being administered to the patient (Hatcher et al, 2004). The system can support clinical area profi les that enable pumps to be confi gured differently for specifi c patient groups in terms of the individual drug used, the dosing units used, the maximum patient weight permissible, the maximum volume to be infused and the maximum rate of the infusion (Snodgrass, 2005; Quinn, 2011).

The DERS system is a software program that sits inside the infusion device and recognises when a deviation from agreed preset limits has been attempted. Each infusion device contains a library of standardised drug infusion concentrations and each concentration can have individual predetermined limits programmed. Limits are established in order to prevent underdosing

› For the fi rst time, a database of potentially harmful adverse events can be constructed ‹

or overdosing of medications and can be set as ‘hard’, in which case they cannot be overridden, or ‘soft’, whereby the user can override the limit. When a limit is reached, the user is alerted via the infusion device’s audible alarm alert, plus an explanatory on-screen visual display.

A review of DERS suggested that:

‘The impact [of introducing a DERS] could result in changes to drug preparation and distribution practices. Drug preparation, for example, could become more centralised in pharmacy departments, with practical and cost advantages. Alternatively, remote drug preparation may not always be ideal because delays in the availability of medicines may result in adverse outcomes for patients’ (NHS Purchasing and Supply Agency, 2008).

Event memory Each time an alert is triggered when a pump is being programmed, the software captures a full record of the events leading up to that alert, providing invaluable ‘near miss’ data on errors averted. For the fi rst time, a database of potentially harmful adverse events can be constructed without relying on voluntary staff reporting, which it is generally acknowledged will only ever capture the ‘tip of the iceberg’. Downloading this information can provide valuable evidence to support practice review and training needs assessment.

Infusion rate calculation Refl ecting its origins in US practice, the library of drugs uploaded by the user into the smart pump is based on one or more standardised concentrations for each drug. Therefore, rather than infusing an individually prepared weight-based concentration at a fi xed rate, the pump automatically calculates the volumetric infusion rate required to deliver the prescribed dose per kilogram of a standardised solution. In many respects, it could be argued that, from the nursing perspective, this function is as valuable an aid to medication safety as the error reduction software itself.

BJN July 2013 CareFusion Supplement 5

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