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Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Mar.
Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet].
Show detailsIntroduction
In this chapter, we discuss two system-level patient safety practices that aim to reduce medication errors associated with infusion pumps, including smart pumps. One practice focuses on implementing structured process changes and redesigning workflows in order to improve efficiencies with pump use. The other focuses on investing in initial and ongoing staff training on the correct use, maintenance, and monitoring of infusion pumps.
Use of infusion pumps, and increasingly smart pumps, has become standard practice in hospitals to administer critical fluids to patients. However, there is still limited research on best practices for reducing errors and improving infusion pump use through workflow and process changes as well as education and training.
Background
Infusion pumps, common medical devices, are used to administer fluids such as nutrients or medications to patients. In comparison to manual administration of fluids, infusion pumps provide the advantage of controlled administration—the ability to deliver fluids in small volumes or at precisely programmed rates or intervals. Many newer infusion pumps are equipped with predetermined clinical guidelines, dose error reduction systems (DERSs), and drug libraries that provide a comprehensive list of medicines and fluids with dose, volume, and flow rate details. These “smart pumps” are designed to address the programming errors that traditional pumps are susceptible to by notifying a user when there is a risk of an adverse drug interaction or when the pump’s parameters are set outside of specified safety limits for the medication being administered. Alerts generated by smart pumps include clinical advisories, soft stops, and hard stops. Clinical advisories provide information about medications within the administering facility’s drug library, including prompts for correct administration, which are programmed into the pump by the facility or larger organization. Soft stops notify users that a selected dose is outside of the anticipated range for a specific medication. These alerts can be overridden without changing the pump’s settings. Hard stops alert users that a dose is out of the institution’s determined range and prohibit the infusion from being administered unless the pump is reprogrammed.1
As infusion pump technology continues to evolve, use of smart pumps in hospitals has increased. A report by the American Society of Health-System Pharmacists found that in 2013, 72.9 percent of all U.S. hospitals were using smart infusion pumps, compared with just 44 percent in 2007.2 Along with this increase, many national organizations have identified implementing smart pumps as a key patient safety tool. The Institute for Safe Medication Practices (ISMP) strongly supports the use of smart pump safety features, and in 2006, the Institute of Medicine identified adoption of smart pumps as a strategy hospitals can use to help reduce the frequency and severity of medication errors.3
Despite the growing support for the use of smart pumps as a safety strategy, however, the literature shows varying results for the effect they have on reducing medication errors. User error, inadequate use of safety technology, incorrect programming, and equipment failures can still occur, significantly impacting patient safety.
Importance of Harm Area
The infusion pump, along with its failures and user errors, can have significant implications for patient safety because of its ubiquitous nature and frequent use to administer critical fluids. Infusion-associated medication errors are mistakes related to ordering, transcribing, dispensing, administering, or monitoring drugs.4 From 2005 to 2009, the U.S. Food and Drug Administration (FDA) received approximately 56,000 reports of adverse events related to the use of infusion pumps, and manufacturers conducted 87 infusion pump recalls.5 Fourteen of these recalls were categorized as Class I, in which there is a reasonable probability that use of the recalled device will cause serious adverse health consequences or death. Although many of the events reported to the FDA were related to deficiencies in device design and engineering, user errors also occurred. One study found that almost half of all infusion-associated medication errors were attributed to deviations in following procedures and documentation requirements.4
Intravenous (IV) infusions in particular pose risks to patient safety due to their complexity and the multiple steps required in their administration. Studies have found that IV infusion is associated with 54 percent of all adverse drug events, 56 percent of medication errors, and 61 percent of serious and life-threatening errors.6 In addition, IV medications are twice as likely to be involved in errors that cause harms when compared to medications delivered via other routes.7
Smart infusion pumps have been implemented to avert possible medication errors; however, the risk of programming errors and equipment failures has not been eliminated. For example, one study found that despite use of smart pumps, 67 percent of the infusions evaluated involved one or more discrepancies.
Methods for Selecting Patient Safety Practices
Initial literature searches for patient safety practices (PSPs) in the infusion pump harm area were focused on systematic reviews and guidelines. Results of these searches were reviewed by harm-area task leads to identify PSPs, iterate on searches as needed, and refine lists of potential PSPs on which to focus this chapter of the report. Then the project Technical Expert Panel and Advisory Group were engaged via a survey to prioritize PSPs for inclusion in the report. These survey results, along with refined recommendations for PSP inclusion, were submitted to the Agency for Healthcare Research and Quality (AHRQ) for review. After several rounds of review with AHRQ, two infusion pump PSPs were selected.
What’s New/Different Since the Last Report
The infusion pump was included as a new topic in the 2013 Making Health Care Safer II report. The brief review focused on implementation of smart pumps, including integrated implementation with larger safety systems such as computerized provider order entry (CPOE) and electronic medication administration records (eMARs). The report concluded that the evidence supporting efficacy of smart pumps for prevention of medical errors is limited, and successful implementation of smart pumps requires extensive planning and usually involves multidisciplinary teams.
References for Introduction
- 1.
- Institute for Safe Medication Practices. Proceedings from the ISMP summit on the use of smart infusion pumps: Guidelines for safe implementation and use. Philadelphia, PA; 2009. https://pdfs
.semanticscholar .org/d7e7/29fa7538e066afda0e637da8fd2f45448d5f.pdf. - 2.
- American Pharmacists Association. Smart infusion pumps: The intelligence behind the technology. 2015. https://www
.pharmacist .com/article/smart-infusion-pumps-intelligence-behind-technology. - 3.
- Institute of Medicine. Preventing medication errors. Aspden P, Wolcott J, Bootman JL, Cronenwett LR. Washington, DC: The National Academies Press; 2007. 480 pp.
- 4.
- Wolf ZR. Strategies to reduce patient harm from infusion-associated medication errors: A scoping review. J Infus Nurs. 2018;36(1):58–65. doi: 10.1097/nan.0000000000000263. [PubMed: 29293199] [CrossRef]
- 5.
- U.S. Food & Drug Administration. Infusion pumps. https://www
.fda.gov/medical-devices /general-hospital-devices-and-supplies /infusion-pumps. Accessed November 13, 2019 - 6.
- Giuliano KK. IV smart pumps: The impact of a simplified user interface on clinical use. Biomed Instrum Technol. 2015;Suppl:13–21. doi: 10.2345/0899-8205-49.s4.13. [PMC free article: PMC4850078] [PubMed: 26444045] [CrossRef]
- 7.
- Biltoft J, Finneman L. Clinical and financial effects of smart pump-electronic medical record interoperability at a hospital in a regional health system. Am J Health Syst Pharm. 2018;75(14):1064–8. doi: 10.2146/ajhp161058. [PubMed: 29987060] [CrossRef]
12.1. PSP 1: Structured Process Change and Workflow Redesign
12.1.1. Practice Description
Established workflows are often used in clinical practice to accomplish patient care goals. In the context of infusion pumps, workflow may include having a staff hand-off procedure for shift changes or requiring two nurses to validate orders, doses, and pump programming for high-alert medications.
Studies have shown that infusion pumps can contribute to inefficiencies and lead to errors. This is largely due to time-consuming, indirect patient care tasks associated with infusion pumps, such as searching for available pumps, priming tubing, manual pump programming, responding to false or unnecessary pump alarms, and managing tangled tubing.1 Inadequate workflows for these tasks can impede communication and cause unnecessary rework, delays, or gaps in care, all which impact patient safety.2 Organizations must also consider how new technology, such as smart pumps, affects workflow and is best implemented in order to drive toward safer use processes. Successful implementation often requires organizational commitment, a shared vision, an understanding of the risks and strengths of current processes, and a unified design that includes all systems and stakeholders.3 In this chapter, we review current practices related to the uses of the infusion pump in clinical settings, including designing workflows, measuring clinical outcomes associated with pump use, and barriers and facilitators to implementation.
12.1.2. Methods
Two databases (CINAHL® and PubMed/MEDLINE®) were searched for “infusion pumps,” “smart pumps,” and related synonyms, as well as “workflow,” “workflow redesign,” “process change,” “product recalls and withdrawals,” and other similar terms, using Boolean operators. Articles included were published from 2008 to 2018. The initial search yielded 168 results. Once duplicates were removed and additional relevant articles from selected other sources were added, a total of 163 articles were screened for inclusion, and full-text articles were retrieved. Of those, nine were selected for inclusion in this review. Articles were excluded if the outcomes were not directly relevant to the PSP addressed in this review.
Key Findings
Outcomes
- Four studies reported medication administration errors, procedural errors, or deviations from hospital policy as clinical outcomes of workflow or process changes.
- Two studies looked at process outcomes related to pump handling; however, mixed results were found.
Implementation
- Four studies identified streamlining and standardization of process and workflows as facilitators.
- Integrating technology and workflow was found to be a facilitator, and three studies demonstrated barriers that occur when implemented infusion pump technology and processes do not align.
General methods for this report are described in the Methods section of the full report.
For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report appendixes A through C.
12.1.3. Review of Evidence
Of the nine studies included in this review, four were observational studies, two were case studies, one consisted of semi-structured interviews, one was a perspective point prevalence study, and one was an online survey. The majority of the studies took place in a hospital setting; four took place outside of the United States.
The included studies primarily examined medication errors and deviations from hospital policy as outcomes of process changes. However, because nearly half of the studies were observational, it is difficult to draw conclusions about the impact of implemented process changes. A summary of key findings related to process changes and workflow redesign for infusion pump use are located in the Key Findings box above. The following section reviews outcomes associated with practice changes, followed by the barriers and facilitators to implementation.
12.1.3.1. Clinical Outcomes
Four of the nine studies reported clinical outcomes, including medication administration errors, procedural errors, or deviations from hospital policy, as outcomes of workflow or process changes. Deviations from hospital policy may indicate that the established processes do not align with the natural workflow of the clinic and that a workflow change is needed to better align current practice with new infusion pump technology.
Russell et al. observed a pediatric intensive care unit (PICU) before and after workflow changes as a result of expansion and implementation of a bidirectional interface between CPOE and the pharmacy system. The researchers compared the discrepancies between medication orders and infusion pump settings, and found that the overall discrepancy rate for medications did not significantly change but the type of discrepancy did. For example, they reported that the proportion of unauthorized medications decreased from 60 percent to 4 percent, but the rate of omitted medications and errors associated with dosage significantly increased.4 In addition, Wiseman et al. conducted a pre/post observational study in Australia and found that, as a result of implementing a requirement for clinical pharmacist annotation on medication charts, medication administration errors dropped from 16.6 percent to 8.1 percent. Subsequent adoption of smart pump technology led the error rate to further decrease to 3.9 percent.5
Two observational studies did not measure the impact of a process change or workflow redesign on errors but reported types and frequency of errors related to an existing medication administration process. Schnock et al. measured policy violations to assess the IV medication administration process and found that the most frequent types of infusion errors were IV labeling (60%) and tubing change policies (35%).6 Similarly, Lyons et al. observed 16 National Health Service trusts in England and found that 47.9 percent of all infusions had at least one procedural or documentation error, of which non-compliance with hospital labeling requirements was the most common.7
12.1.3.2. Process Outcomes
Two studies looked at process outcomes related to pump handling. DeGraff reported that in response to a shortage of IV pumps and staff members hoarding pumps, a hospital implemented a new procedure for cleaning and restocking pumps. This process change resulted in decreasing the steps for pump handling from 26 to 8.8 The results of process change were more mixed in a study by Chaturvedi et al., in which a hospital integrated its electronic health records (EHRs), CPOE, smart pumps, and barcode-assisted medication administration (BCMA) systems, and engaged in multiple efforts to standardize workflows. The integrated system significantly reduced the amount of time required by nurses to program medications; however, nurses reported that their overall workload did not decrease and that there was an increase in the number of computer steps required to administer medications.9
12.1.3.3. Economic Outcomes
Biltoft and Finneman measured cost savings of integrating smart pumps with electronic medical records (EMRs) after determining the study hospital was losing revenue due to a lack of sufficient documentation to support the billed charges or missing documentation, specifically stop times, in the medication administration record for outpatient infusions. The researchers found that implementation of the integrated smart pump-EMR provided accurate start and stop times which reduced both mean lost charges for infusions (from 11.9% to 7.4%) and lost revenue (from $980,000 to $610,000).10
12.1.4. Implementation
12.1.4.1. Summary of Evidence on Implementation
Changing processes or redesigning workflows for infusion pumps can be a complex undertaking that includes a variety of interventions. The studies included in this review implemented or analyzed process changes that were specific to the needs of the hospital or infusion pump system and may not be generalizable. This section reviews some of the common facilitators and barriers that emerged in relation to implementing process changes or redesigning workflows to improve infusion pump use.
12.1.4.2. Facilitators and Barriers
12.1.4.2.1. Facilitators
Standardization and streamlining of processes and workflows were identified as main facilitators of optimal infusion pump use across multiple studies. For example, DeGraff found that a hospital was able to significantly improve utilization of IV infusion pumps by streamlining its workflow for cleaning and restocking pumps.8 Biltoft and Finneman streamlined nursing workflows by reconfiguring rooms so that infusion pumps and EHR computers could be accessed at the same time, which led to more accurate infusion documentation.10 In addition, Schnock et al. note that by reviewing existing policies, the study team recognized the benefits of using standardized tubing labels to indicate when a nurse should change tubing.6 Finally Chaturvedi et al. found that hospital leaders viewed standardization of nursing workflow as extremely beneficial because it was perceived to reduce the frequency of nursing workarounds that could cause patient harm.9
The included studies also highlighted the importance of integrating technology and workflows. Pinkney et al. noted that implementation of smart pumps should be viewed as part of a larger safety initiative rather than just a technology upgrade and that in order to be successful, implementation should focus on design of workflows. For example, they found that implementing design-oriented solutions that constrain users to follow the preferred workflow, such as defaulting users into using the drug library, helps ensure users employ the safety features.11 Similarly, Chaturvedi et al. concluded that implementation of an IV clinical integration system is not only a technology intervention but requires workflow changes to be successful.9
In addition, engaging multiple members of the care team in workflow redesign is an important facilitator. For example, Wiseman et al. found that clinical pharmacists play a key role in reducing error rates and should be consulted when configuring workflows.5 Russell et al. found that after the PICU was relocated and expanded, pharmacist and dietician presence on rounds increased, resulting in greater collaboration between them and those responsible for ordering medications. This collaboration helped reduce the number of reorders.4
12.1.4.2.2. Barriers
Lyons et al. noted that in some cases procedural deviations are not representative of inadequate care practices but rather demonstrate a poor fit between hospital policy and everyday practice. If workflows do not align with new technology or policies are implemented that are not compatible with natural workflows, then errors or workarounds can occur that impact patient safety. For example, they found that staff reported deliberate deviations that would benefit patients but conflicted with official rules and formal procedures, such as giving patients fluids that had not yet been prescribed because a doctor was unavailable.7 Schnock et al. found that information such as infusion start time, which was necessary to document on paper labels, was no longer needed after implementation of CPOE, eMAR, and BCMA, since it was automatically entered into the system. This example illustrates that when new technology is implemented, processes such as documentation workflows must be reevaluated for relevance.6 Furthermore, Russell et al. noted that prior to implementation of a bidirectional interface between CPOE and the pharmacy system, if a provider requested a new urgent medication, the pharmacist could deliver the medication but would be unable to reconcile the order so it appeared as an unauthorized medication. In this case, implementing the new system rectified the misalignment between technology and the established workflow by allowing pharmacists to immediately reconcile verbal orders from physicians.4
Staff buy-in and hospital resources were also identified as barriers to process changes. Chaturvedi et al. reported challenges gaining buy-in from nurses to adopt workflow changes and noted that frontline staff often expressed concerns regarding the patient safety implications of workflow changes.9 Iacovides et al. also noted that when implementing infusion pump technology, organizations need to ensure that adequate infrastructure and resources are available, and that the affected staff believe that the change is worth the time and money required.12
12.1.4.3. Resources To Assist with Implementation
As a result of a 2008 summit, the ISMP published Proceedings from The ISMP Summit on the Use of Smart Infusion Pumps: Guidelines for Safe Implementation and Use. A second summit was held in 2018, and the guidelines are currently being updated. The revised and expanded guidelines are designed to support optimization of smart pump technology and assist organizations in transition to smart pump interoperability. In 2010, the FDA undertook the Infusion Pump Improvement Initiative to support benefits of infusion pumps while minimizing risks. The FDA also has a list of infusion pump risk reduction strategies organized by type of user.
12.1.4.4. Gaps and Future Directions
There is strong evidence describing the frequency and type of medication and procedural errors associated with infusion pump use, however, there is limited research on workflow and process changes that can be implemented to address those errors. More implementation studies are needed to understand best practices for reducing errors and improving infusion pump use through workflow and process changes.
References for Section 12.1
- 1.
- Weinger MB, Kline A. Reflections on the current state of infusion therapy. Biomed Instrum Technol. 2016;50(4):253–62. doi: 10.2345/0899-8205-50.4.253. [PubMed: 27413829] [CrossRef]
- 2.
- Cain C, Haque S. Organizational workflow and its impact on work quality. In: Hughes R, editor. Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2018. https://www
.ncbi.nlm .nih.gov/books/NBK2638/. - 3.
- Troiano D, Morrison J, Federico F, et al. Safely automating the medication use process. Not as easy as it looks. J Healthc Inf Manag. 2009;23(4):17–23. PMID: 19894482. [PubMed: 19894482]
- 4.
- Russell RA, Triscari D, Murkowski K, et al. Impact of computerized order entry to pharmacy interface on order-infusion pump discrepancies. J Drug Deliv. 2015;2015:686598. doi: 10.1155/2015/686598. [PMC free article: PMC4667052] [PubMed: 26664749] [CrossRef]
- 5.
- Wiseman ML, Poole S, Ahlin A, et al. Reducing intravenous infusion errors: An observational study of 16 866 patients over five years. J Pharm Pract Res. 2018;48(1):49–55. doi: 10.1002/jppr.1339. [CrossRef]
- 6.
- Schnock KO, Dykes PC, Albert J, et al. The frequency of intravenous medication administration errors related to smart infusion pumps: A multihospital observational study. BMJ Qual Saf. 2017;26(2):131–40. doi: 10.1136/bmjqs-2015-004465. [PubMed: 26908900] [CrossRef]
- 7.
- Lyons I, Furniss D, Blandford A, et al. Errors and discrepancies in the administration of intravenous infusions: A mixed methods multihospital observational study. BMJ quality & safety. 2018;27(11):892–901. doi: 10.1136/bmjqs-2017-007476. [PMC free article: PMC6225796] [PubMed: 29627799] [CrossRef]
- 8.
- Degraff B. As medical devices proliferate, asset management is key. Biomed Instrum Technol. 2013;47(2):123–7. doi: 10.2345/0899-8205-47.2.123. [PubMed: 23600348] [CrossRef]
- 9.
- Chaturvedi RR, Etchegaray JM, Raaen L, et al. Technology isn’t the half of it: Integrating electronic health records and infusion pumps in a large hospital. Jt Comm J Qual Patient Saf. 2019;45(10):649–61. doi: 10.1016/j.jcjq.2019.07.006. [PubMed: 31500950] [CrossRef]
- 10.
- Biltoft J, Finneman L. Clinical and financial effects of smart pump-electronic medical record interoperability at a hospital in a regional health system. Am J Health Syst Pharm. 2018;75(14):1064–8. doi: 10.2146/ajhp161058. [PubMed: 29987060] [CrossRef]
- 11.
- Pinkney S, Trbovich P, Fan M, et al. Do smart pumps actually reduce medication errors? Biomed Instrum Technol. 2010;44(s1):64–9. doi: 10.2345/0899-8205-44.s1.64. [CrossRef]
- 12.
- Iacovides I, Blandford A, Cox A, et al. Infusion device standardisation and dose error reduction software. BR J Nurs. 2014;23(14):S16, S8, S20 passim. doi: 10.12968/bjon.2014.23.sup14.s16. [PubMed: 25158362] [CrossRef]
12.2. PSP 2: Staff Education and Training
12.2.1. Practice Description
The literature shows that inadequate training is often associated with knowledge and rule-based mistakes when using infusion pumps.1 These medication errors can occur when staff are inexperienced, including being unfamiliar with the medication, environment, procedure, or equipment. In addition, lack of training can lead to overriding of smart pump safety features erroneously. Although smart pumps can be a beneficial tool to reduce medication errors attributed to manual programming, using the embedded drug libraries and DERSs is not mandatory. The literature shows that nurses commonly bypass the safety features because the drug library parameters are not customized for their patient population, it takes too much time to program the pumps, and there are too many alarms.2 To prevent overriding safety features and programming errors, some hospitals invest in initial and ongoing staff training on the correct use, maintenance, and monitoring of smart pumps. Hospitals may also implement standard procedures for pump management and provide education on the use of the standardized protocols.
The FDA recommends providing training and educational activities for all employees designed to promote the safe use of infusion pumps, including drug library usage, as a risk-reduction strategy for facility administrators and managers.3 In addition, the ISMP, in its draft guidelines from the ISMP National Smart Infusion Pump Summit in 2018, states that organizations should establish a standard approach for staff training and ensure that the education provided emphasizes the intended safety benefits.
This section reviews studies of education and training programs implemented to address infusion pump errors by examining clinical and process outcome measures, as well as barriers and facilitators to implementation.
12.2.2. Methods
Two databases (CINAHL® and PubMed/MEDLINE®) were searched for “infusion pumps,” “smart pumps,” and related synonyms, as well as “in-service,” “staff education,” “staff training,” and other similar terms, using Boolean operators. Articles included were published from 2008 to 2018. The initial search yielded 104 results. Once duplicates were removed and additional relevant articles from selected other sources were added, a total of 107 articles were screened for inclusion and full-text articles were retrieved. Of those, 12 were selected for inclusion in this review. Articles were excluded if the outcomes were not directly relevant to the PSP addressed in this review, the article was out of scope, or study design was insufficiently described.
General methods for this report are described in the Methods section of the full report.
For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report appendixes A through C.
12.2.3. Review of Evidence
A summary of key findings related to staff education and training is located in the call-out box. The following section reviews the studies in more depth. Of the 12 studies included in this review, 5 were performance or quality improvement initiatives. Other study designs included a longitudinal study, observational study, snapshot audit, and randomized controlled trial. Ten of the 12 studies took place in a hospital setting, two of which were pediatric hospitals. Two studies took place in a simulation laboratory used for training. Three of the studies took place outside the United States.
Key Findings
Outcomes
- Four studies measured clinical outcomes for the impact of investing in education on the correct use, maintenance, and monitoring of smart pumps, including three that reported a decrease in medication errors and one that reported a decrease in the number of adverse drug events.
- Two studies found an increase in nurses’ adherence to using the medication safety software library as a result of education.
Implementation
- Five studies identified the type and content of education provided as facilitators.
- One of the studies noted that time and energy constraints on nurse educators can be barriers to implementing large hospital-wide education programs.
To evaluate the impact of implementing staff education and training on the correct use, maintenance, and monitoring of infusion pumps, the studies measured clinical outcomes as well as process outcomes related to compliance and use of safety features. The review’s key findings are located in the box to the right.
12.2.3.1. Clinical Outcomes
Of the 12 studies, 4 reported clinical outcomes for the impact of investing in education on the correct use, maintenance, and monitoring of smart pumps. Measured clinical outcomes included the number of medication errors, severe harms adverted, and adverse drug events.
A study by Ferguson et al. examined implementation of mandatory training over 4 months on the proper usage of patient-controlled analgesia pumps for all registered nurses (RNs) who use the pumps. The study found that the number of pump errors reported over 3 months significantly decreased from eight prior to the intervention to one after the intervention, addressing the primary cause of medication errors in the 22-unit hospital.4 Van der Sluijs et al. used a Lean approach based on feedback and training to implement a fixed, dedicated moment of time to double-check medications and a standard operating procedure for changing syringe pumps. The Lean philosophy is a quality improvement method that aims to improve processes and reduce errors by paying attention to little problems. The implementation was communicated to clinical staff through lessons and instructions, and the authors found that over 18 months, the overall percentage of medication errors (the percentage of syringes used with a medication error) dropped from 17.7 percent to 2.3 percent.5 In addition, Giuliano measured the impact of user training in a simulation lab on the frequency of programming use error for three IV smart pumps and found that use errors decreased from 30 percent to 7 percent, 17 percent to 3 percent, and 8 percent to 1 percent. Giuliano also found that programming time was significantly shorter after user training.6
One study measured different clinical outcomes of proper infusion pump usage: the number of severe harms adverted and adverse drug events. Orto et al. sought to increase compliance with use of the smart pump specifications by assigning nurse champions to conduct monthly educational sessions with RN staff, both individually and in groups, to ensure that they were using the smart pumps and their drug library parameters. The authors found that the aggregate number of severe harms averted (defined as high risk drugs being programmed by the nurse 2.5 times or greater than recommended) per 1,000 infusion starts over 6 months decreased from 0.68 pre-intervention to 0.44 post-intervention, indicating there were fewer episodes of severe infusion harms. In addition, the number of adverse drug events more severe than level 2—defined as events that reach the patient and require intervention and monitoring—decreased from four to one from pre-implementation to post-intervention.7
12.2.3.2. Process Outcomes
Studies examining the impact of implementing education and training on proper usage of infusion pumps measure compliance with pump technology protocols and adherence to using safety software. In a study by Gavriloff, researchers implemented staff education focusing on the correct use of the safety software and the benefits of preventing medication errors as part of a multicomponent intervention. The goal of the education program was to improve nurses’ adherence to using the medication safety software drug library created by the healthcare organization. Just 1 month after it was implemented, the adherence rate had increased from 25 percent at baseline to 68 percent. The adherence rate further increased to 85 percent after the Chief Nursing Office sent a follow-up communication encouraging nurses to use the medication safety software.8 In addition, Orto et al. measured compliance with use of the drug library in smart pumps in a hospital where not using the drug library constituted noncompliance with hospital policy. They found that, after implementation of a nurse-led smart pump champions program, compliance among RNs significantly increased from 85 percent to 92 percent. These gains were sustained post-intervention with a compliance of 92.9 percent and 93.3 percent at 3 and 6 months, respectively.7
One study examined the impact of an education intervention on the use of smart pump safety features. In a pre-intervention survey of nurses, Herring et al. found that 88.6 percent of respondents reported agreeing or strongly agreeing that training and education were adequate, and 82.8 percent agreed or strongly agreed that they knew how to use the drug library. However, 44 percent of the open-response comments requested additional training on the safety features. After implementing an education program that included a mandatory active-learning practical-skills laboratory and an optional education presentation that reviewed evidence of improved patient safety when smart pump safety features are fully used, the authors found that use of the pump mode with all safety features enabled increased from 5.5 percent to 30.5 percent.9
12.2.3.3. Economic Outcomes
Of the 12 studies, only 1 study measured cost outcomes. Orto et al. calculated potential cost avoidance, defined as costs that would have been incurred if the severe harms had not been averted. The study found the costs avoided because severe harms were averted came to $367,500 at the end of the intervention period compared to $612,500 6 months before the intervention. The lower cost is associated with lower numbers for severe harms averted due to the use of smart pumps.7
12.2.4. Implementation
12.2.4.1. Summary of Evidence on Implementation
Although limited evidence is provided in this review, common themes regarding implementation of an education intervention emerged. This section reviews some of the facilitators and barriers to implementing staff training on the correct use, maintenance, and monitoring of smart pumps.
12.2.4.2. Facilitators and Barriers
12.2.4.2.1. Facilitators
The type and content of education provided were identified as important facilitators to successful implementation. For example, Herring et al. found that education from the device manufacturer alone may be insufficient and that implementing a hands-on training targeting identified obstacles was essential to increasing use of safety features.9 Similarly, Nemeth et al. found that in order to be most successful, the training program should include opportunities for participants to apply learning through discussing case examples. They also found that training should provide information about the most relevant smart pump functions and the potential challenges nurses may encounter in using them. Virtual training systems have also been shown to facilitate learning, although the results are mixed.10 In a study by Luctkar-Flude et al., participants who completed an online virtual IV pump learning module reported that the module enhanced their knowledge of programming; however, most students did not feel it increased their ability to program certain types of infusions.11 Quattromani et al. compared use of a traditional training method with a faculty member to use of an interactive smart pump training app and found no significant difference in outcomes related to medical knowledge, performance, or learner confidence.12
In addition to the type of training, the choice of trainer can be a facilitator. For example, Orto el al. implemented a nurse champion-led group to improve smart pump compliance due to the success their hospital had in the past with this type of intervention.7 Finally, Gavriloff found that training that focuses on “why” smart pumps are used instead of just “how” to use smart pumps is important to increase adherence. By understanding the safety software, nurses are able to provide ongoing evaluation on needed revisions and refinements.8
12.2.4.2.2. Barriers
Limited knowledge transfer and constrained hospital and staff resources were reported as potential barriers to implementation. For example, Lee found that when nurses move to different wards, they are often exposed to new devices on which they have not been trained.13 In addition, Ferguson et al. note that after nurses are trained, they may not retain competency on use of a particular type of smart pump if they commonly use multiple types of pumps or if they infrequently use any pumps. Furthermore, Ferguson et al. note that establishing hospital-wide education programs can be a significant undertaking for staff development departments, and that the time and energy constraints on nurse educators should be carefully considered and planned.4 Carayon et al. highlight the importance of planning by noting that a lack of attention devoted to the implementation planning process resulted in nurses reporting more negative perceptions of usefulness of information and clarity of training materials 6 weeks and 1 year after the time of the initial training.14
Resistance to culture change was also identified as a potential barrier. Subramanyam et al. found that, despite being educated on the use of standardized pump programming, nurses were resistant to a culture change from the old processes to a new two-person verification process.15 Orto et al. noted that they implemented a nurse-led program focusing on promoting compliance, partnering with pharmacists, and supporting manual audits to help create a culture of safety.7
12.2.4.3. Gaps and Future Directions
Although the use of smart pump technology has increasingly become standard practice in hospitals, there is limited evidence on best practices for education and training on the proper usage of smart pumps. More research is needed to understand why clinicians commonly bypass smart pump safety technology and what type of training should be implemented to limit medical errors.
References for Section 12.2
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Conclusion and Comment
The two patient safety practices reviewed in this chapter aim to reduce medication errors by implementing initiatives to improve the use, maintenance, and monitoring of infusion pumps. The review of evidence shows that protocols and workflows are integral to proper technology use and therefore should be carefully considered when implementing new infusion pump technology. The studies included in this review provide support for streamlining and standardizing workflows. However, more implementation studies are needed to better understand the impact of workflow changes and best practices for effective integration of processes and infusion pump use. The evidence also shows support for providing education and training on infusion pumps to promote safe use. In these studies, the type and content of education provided were highlighted as facilitators, while limited knowledge transfer and resistance to culture changes were identified as barriers.
Reviewer: Giulia Norton, Ph.D., M.P.H.
- Infusion Pumps - Making Healthcare Safer III: A Critical Analysis of Existing an...Infusion Pumps - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices
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