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IMPLEMENTING AND EVALUATING DOSE ERROR REDUCTION SOFTWARE


Implementing and evaluating the patient safety benefi ts of dose error reduction software in electronic infusion devices in an NHS Hospital Trust


attention (Daily Telegraph, 2010; Daily Mail, 2011). The T


Abstract A review of all dose error reduction software (DERS) alerts displayed in electronic infusion devices (‘smart pumps’) was undertaken in an NHS Hospital Trust over 12 months.


There were 265 880 infusion starts recorded. The majority of infusions (173 891 (65.4%)) were found to have been started using the 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 dose rate limit and 1331 (0.5%) above and 1538 (0.6%) below the soft dose rate limits. Of these, 317 (8.6%) resulted in the ‘error’ being corrected by reprogramming the infusion rate within set limits, 478 (12.9%) were cancelled and 2452 (66.3%) were over- ridden with the rate of infusion unchanged. For 453 (12.2%) the actions were not recorded in a way that could be included in reports for analysis.


Implementation of this technology has enabled infusion rate errors involving critical infusions containing high alert medicines to be avoided. These types of infusion errors could also be avoided in other NHS Trusts if DERS were used.


he consequences of errors when nurses use electronic infusion devices to administer drug infusions can be fatal and generate media


National Reporting and Learning System receives large numbers of patient safety incidents from the NHS involving the unsafe use of injectable medicines and some of these incidents cause death or serious harm to patients (National Patient Safety Agency, 2007; 2010b).


Dose error reduction software (DERS) in ‘smart pumps’ has been available from infusion device manufacturers in Europe since 2002 (Upton, 2012). DERS, included as part of the information technology system in infusion devices, provides an electronic double check to minimise the risk of serious drug infusion errors. The software recognises when a deviation from agreed preset dose and rate of administration limits has been attempted and displays an alert screen and audible alarm to the user. This provides the opportunity for the user to amend or cancel the entered dose or rate of administration before the infusion is started. As part of DERS, a library of locally agreed standardised drug infusion concentrations is required. Each infusion can have individual predetermined limits programmed. Limits are established in order to prevent under or overdosing of medications and can be set as ‘hard’, in


Authors: David Cousins, Senior Head, Safe Medication Practice and Medical Devices, NHS England, 4–8 Maple Street, London W1T 5HD


Edmund Cartwright, Associate Director (CNO) Professional Affairs, and Taryn Keyser, Antimicrobial Pharmacist, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hants


BJN July 2013 CareFusion Supplement 9


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