PATI ENT SAFE T Y
infusions were cancelled, 831 had hard limit alerts – 25 of them with up to 10-50 times higher doses, and 196 harms were avoided.6 In a 62-month review of a Spanish paediatric unit using smart pumps, 283 programming errors were intercepted, with 58% of intercepted errors involving high- risk drugs, such as adrenergic agonists and antagonists, sedatives, analgesics, neuromuscular blockers, opioids, potassium and insulin. Examples of errors intercepted included an infusion of thiopental initially programmed for 18mg/kg/h and corrected to 8mg/kg/h, the upper limit for that drug; and an initial programming for insulin 75-times higher than the maximum limit.7 A systematic review by Ohashi et al sought to assess both the benefits
(2014)8
and negative effects of smart infusion pumps. The researchers concluded that the benefits of using smart pumps included intercepting errors such as the wrong rate, wrong dose, and pump setting errors, as well as the reduction of adverse drug event rates, practice improvements, and cost effectiveness. However, the issues or negative effects related to using smart pumps were lower compliance rates of using smart pumps, the overriding of soft alerts, non-intercepted errors, or the possibility of using the wrong drug library.
The authors concluded that smart pumps
“reduce but do not eliminate programming errors” and stated that although the hard limits of a drug library play a main role in intercepting medication errors, soft limits were not as effective as hard limits because of high override rates.
The authors wrote: “Compliance in using
smart pumps is key towards effectively preventing errors. Opportunities for improvement include upgrading drug libraries, developing standardised drug libraries, decreasing the number of unnecessary warnings, and developing stronger approaches to minimise workarounds. As
with other clinical information systems, smart pumps should be implemented with the idea of using continuous quality improvement processes to iteratively improve their use.”
Is there a case for mandating the use of smart pumps?
In 2018, the National Association of Medical Device Educators and Trainers (NAMDET) established a Dose Error Reduction Software (DERS) and Smart Pump position statement group to look at the evidence, review DERS in use, and gather data around smart pumps and their ability to reduce risk. The culmination of their meetings and data gathering resulted in the publication of a report, recently published in November 2020.9
The group comprised NHS stakeholders from a range of specialties (including pharmacy, medical devices training, anaesthesia and oncology), as well as infusion pump manufacturers – such as
Smart pumps are just one piece of the jigsaw and ongoing checks, upgrades and validation will still be required. The ultimate effectiveness of any DERS system is reliant on the pump hardware capabilities, connectivity infrastructure and a multidisciplinary team approach with full engagement of the clinical users, the technical team, risk and governance, pharmacy and of course IT and support services. NAMDET (2020)
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WWW.CLINICALSERVICESJOURNAL.COM
Baxter Healthcare, ICU Medical, BD Medical, Smiths Medical and B Braun. The position statement highlighted the fact that: “Despite many published papers outlining the advantages and benefits of using ‘smart pumps’ with DERS, its use in the UK is less than 30%, with most using no DERS at all.”
NAMDET called for the increased/ mandated use of DERS and smart infusion pumps, to reduce variation in care and improve patient safety. The report further pointed out that, while there is 80-85% penetration of smart pumps in the US, it is far lower in the UK. In a preliminary review from the ECLIPSE study, of 1,124 patients receiving 1,739 infusions in 14 hospitals, 71% of patients (1,234 infusions) did not receive infusions via smart pumps.10 The group added that, at present, there is no national perspective (for example, from NHS Improvement), on the issue of smart pumps increasing patient safety, since there is very little DERS error reporting nationally. The majority of information is held at an organisational level and not shared.9 The group issued the following six position statements: Position Statement 1.
Define what we mean by DERS Smart pumps providing electronic infusion Dose Error Reduction Systems (DERS) are a suite of safety programmes designed to help reduce variation through standardised medication rates and concentrations from infusion pumps. This will take the form of a regularly updated library of drugs and built-in infusion pump safety software with safety limits intended to help reduce dosing errors, reduce variation in care and provide programmable alarms to help reduce patient harm.
MAY 2021
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