PATI ENT SAFE T Y
technology effectively across the NHS, rather than on the technology itself. The researchers examined these barriers through a ‘ten key considerations’ framework which looked at what is needed at each stage to ensure a successful implementation. This covered everything from clarifying why the change is needed to constant evaluation once the system is in place. Using the framework, the investigation identified the safety risks that would need to be managed at each stage. The investigation highlighted the following main implementation challenges: National consistency in drug libraries – smart infusion pumps have an inbuilt DERS which requires the use of a drug library. The investigation found that drug libraries were developed ‘locally’ and that there is no agreed national drug library for use in NHS. They also found that there is no national guidelines or standards on how to implement the libraries.
Significant changes in processes – introducing the technology requires significant changes to prescribing and administration processes in Trusts. The investigation found that procedure and guidance documents often needed updating, and variations in medication practice were ‘locally managed’ and were rarely shared within and between hospitals.
Provision of specialist IT support and infrastructure – substantial IT infrastructure is needed to support the integration of smart pump technology. Software is needed to upload the drug library to smart pumps, download data logs (including any errors detected) and monitor the status of each smart pump. The investigation highlighted that maintaining the required IT infrastructure required specialist staff roles and often a new skill set.
The investigation found that the implementation of smart pump functionality would benefit from the use of risk management practices, as requirements are complex and similar to the introduction of a new IT system. Existing NHS clinical risk standards could provide a basis for both manufacturers and Trusts to work together to manage risks. The report stated that, when introducing new technology within a hospital, it is important to understand what problems the technology has been designed to tackle and why change is needed. The HSIB pointed out that previous generations of pumps had an unrestricted range of programming possibilities. However, smart pumps can provide either a ‘soft limit’ warning, which allows the user to override the limit and continue administering, or a ‘hard limit’ warning, requiring the pump to be reprogrammed using acceptable values.
Although many newly procured pumps have inbuilt DERS functionality, smart pumps can be used without the DERS functionality being enabled. In addition, the report also pointed out that smart pumps have an inbuilt event log. This creates a detailed record of medications that have been given including the drug name, dose, volume administered, infusion rate and time. The event log also includes instances where the DERS system has prevented an overdose or has been overridden. DERS alerts provide opportunities for learning and improvement if medication incidents are analysed and understood, leading to changes in infusion practice. Although event logs are potentially a useful data source for improving patient safety, the investigation found that they are often not routinely inspected unless patient harm has occurred. The researchers pointed out that deciding not to analyse this data as part of ongoing quality improvement is a missed opportunity.
The HSIB added that, in other safety- critical industries, analysing log data that could potentially improve practice is often mandatory.
The next generation of ‘smarter’
smart pumps are interoperable and can interact with other clinical IT systems such as a patient’s electronic prescription/ administration chart and electronic health record. The HSIB report pointed out that these interoperable systems can capture a wider range of possible medication errors such as the wrong drug being administered. HSIB highlighted the fact that there are hospitals in the US that use these interoperable systems to deliver medication autonomously, based on an electronic prescription, and concluded that “NHS Trusts may be looking to procure this technology.” Scott Hislop, principal national investigator at HSIB, commented: “The purpose of the investigation wasn’t to endorse or examine the advantages or disadvantages of the technology but to understand why it can be difficult to implement in hospitals and where this might introduce some new risks to patient safety. “Our investigation identified that these risks have been seen in Trusts of different sizes across England. We have worked closely with manufacturers, regulators and national bodies and it’s clear a system-wide approach is needed to share learning and manage those risks effectively. “The ten key considerations framework which underpins the report helped us to see where there may have been gaps at a national level and this has been reflected in the safety recommendations we have made. Setting out what an effective implementation journey should look like will help NHS Trusts to use smart infusion pump technology to its
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full benefit, reducing the risk of serious harm to patients.”
Human Factors: the role of the manufacturer
While safety could be enhanced through the next generation of interoperable smart pumps, the need for manufacturers to collaborate with end users to fully understand potential human factors, when designing smart pump technologies, remains imperative. In an effort to drive improvement in patient safety, BD has set up a number of focus groups to understand the contributing factors that need to be addressed, for example.
“Human factors, system-based issues and technology design can all influence risk,” commented Kevin Dand, country business leader for medication management solutions at BD.
“However, one of the most important factors, identified by our focus groups, is staff shortages. On the ward or ICU, there are significant pressures around staff shortages, which are now amplified by the pandemic. Planned resources in ICU are not available all of the time – in reality, staff are often doing other things and are not able to focus all of their attention on infusion tasks. “The focus groups told us that there are lots of telephone calls, chasing equipment or medications, and the pharmacy often receives numerous calls from the ward. Sometimes staff may even need to physically attend. There can be a lot of distraction in this activity, pulling staff away from the delivery of care,” he explained. He pointed out that, even without the added pressures of the pandemic, caring for patients with infusions can be a difficult task. Nurses need to make sure each infusion is delivering the right therapies, while dealing with many demands on their time. With the move to more single patient rooms, it is also becoming harder for nurses to keep track of every infusion. The development of software that enables staff to check and manage the ward’s infusions on their computer or tablet, as they move around, can help improve the management of infusion processes and patient safety, therefore.
“Staff want infusion technology to improve communication and improve the efficiency of the system. Solutions that can improve knowledge between teams and institutions is of vital importance and has the potential to reduce medication errors. The focus groups also said that they want technology that can support decision making,” Kevin reported.
The key to this, he believes, is the development of intelligent software: “The latest smart pump technology offers suggestions for improved workflows and drug inventory management, as well as providing drug-specific clinical
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