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Smart infusion pumps for intravenous administration

Errors in intravenous (IV) medicine administration can result in significant patient harm or treatment failure. A pre and post-intervention study (Level III-3) examining the impact of a smart infusion pump38 on IV administration errors was undertaken in an acute hospital in Melbourne in 2008. In the pre-intervention stage an audit undertaken by an independent observer over 41 working days recorded prescribing and administration details for medicine infusions when conventional pumps (IMED Gemini Volumetric Infusion) were used in the hospital. The smart pump intervention used in the study was an Alaris GP Volumetric Pump with software called Guardrails which includes a medicine library. The medicine library included standard concentrations, dosing units and maximum and minimum infusion rates and was developed for local requirements of the hospital. The software provided ‘soft’ and ‘hard’ alerts in under-dose and overdose scenarios. In the case of ‘hard’ alerts, the user would be notified that the dose was above the maximum level in the medicine library and the infusion would not be allowed to proceed until re-programmed to an acceptable dose level. Twenty months after the introduction of the smart pumps, IV medicine administration errors (defined as any deviation of the rate or concentration set on the pump when compared to the medication chart) and clinical significance were audited for a period of 27 days. The clinical significance of errors was assessed independently by an emergency physician and clinical pharmacist. There were 432 infusions audited in the pre-intervention period and 266 in the post- intervention period. In the post-intervention, period 62% of infusions (165/ 266) were administered using the Guardrails software.

Major findings of the study included:

 during the pre-intervention period, 18% of infusions (76/432) had one or more errors recorded compared to 9.4% of infusions (25/266) following the introduction of the smart pumps (p=0.003)

 of the 165 infusions administered using Guardrails software, only 3.6% (six infusions) had errors identified (p<0.001 compared to pre-intervention)

 when medicines were infused using the Alaris GP pumps without Guardrails, 19% (19/101) had errors which was no different from the pre-intervention (p = 0.8)

 the error rates were significantly lower when the smart pump was used with the Guardrails software compared to the pump without the software (p<0.001)

 when Alaris GP pumps with Guardrails were used there were no errors of ‘extreme’ clinical significance or ‘high’ clinical significance compared to the pre-intervention period where there was one error of ‘extreme’ clinical significance and 30 errors of ‘high’ clinical significance

 there was a statistically significant reduction in errors of ‘high’ or ‘extreme’ clinical significance between the two study periods (p=0.03).

This study (Level III-3) suggests that the Alaris GP smart pump with Guardrails can significantly reduce intravenous administration errors in an Australian acute care setting. The study findings also suggest that use of the software containing a medicine library and alert system (tailored to the local requirements) must be used with the pump for the error reduction to occur.

Tall Man lettering to reduce medicine selection errors

Confusion between medicine names has been identified as significant cause of medication error in Australia and internationally.87 Tall Man lettering has been suggested as one strategy to reduce these types of errors for medicine names that sound or look-alike. Tall Man lettering is a technique of using selective capitalisation of parts of a medicine name to differentiate similar looking medicine names more easily (e.g. cefUROXime and cefOTAXime).87

Two studies published since 2008 were identified that examined the use of Tall Man lettering in Australia. One study was a laboratory-based study that examined the rates of errors in identification of medicine names by pharmacists and junior medical officers when names were presented in one of three formats: natural case, Tall Man and random capitalisation1. This study found no significant differences in errors with any one type of format. A second study described the successful

introduction of Tall Man letters as a safety strategy in a hospital network in Victoria.88 Labels using Tall Man lettering were added to dispensary shelves and ward medicine storage areas and Tall Man lettering was introduced into the pharmacy dispensing software. However, no studies were located that examined the impact of Tall Man lettering on error rates or patient outcomes.

Medicine delivery and storage in hospital wards

A pre- and post-intervention study (Level III-3) undertaken in 2008/09 in a Tasmanian rural/regional hospital assessed the impact of a ward pharmacy technician service to facilitate medicine delivery to a medical ward.89 In the pre-intervention period, the medicine distribution system on the ward consisted of imprest and individual dispensing with medicines administered to patients from

medicine trolleys. In the post-intervention period, the pharmacy technician serviced the medical ward's imprest and individual dispensing and stored medicine in individual bedside drawers. They also contacted the clinical pharmacist if they identified discrepancies between items in bedside drawers and medicine orders or found incomplete or ambiguous medicine orders. Two audits examining missed doses were conducted pre-intervention (May and December 2008) and two further audits (including missed doses) were conducted post-intervention (February and June 2009). There was a high rate of missed doses pre-intervention with 8.9% of regular doses (72/811) and 7.9% of regular doses (52/657) missed in the first and second pre-intervention audit, respectively. In both post-intervention audits there were no missed doses detected (p<0.01).

Standardising medication charts

A study undertaken in Queensland to improve insulin management in hospitals90 examined the effect of form redesign and standardisation to improve the prescription and administration of insulin (details of this study relating to prescribing errors are described below in the section Systems to improve prescription writing: Standardising Medication Charts). The study was undertaken in four tertiary and regional hospitals and used a pre- and post-intervention design (Level III-3). A state-wide expert panel, including endocrinologists, physicians, pharmacists, diabetes educators and

medication safety nurses, was involved in the design of two standardised charts, one for intravenous insulin and one for subcutaneous insulin. Consensus and available evidence were used to guide the development process. The forms were also assessed using prescribing and administration scenarios and then piloted with format changes applied where required. The charts were designed to allow all documentation for prescribing and administration of insulin to be included on the one chart. They also included prompts for prescribers to reduce unsafe documentation (such as the elimination of the abbreviation ‘u’ for units). A decision support tool for managing hypoglycaemic episodes was also developed and incorporated. The forms were implemented with education for hospital staff from site-based project officers over a period of eight weeks.

Insulin management was measured through an audit of documentation and blood glucose control before, and three months after, the implementation of the charts. There were a total of 117 patients in the pre-intervention audit and 82 patients post-intervention. In an audit of intravenous insulin administration documentation the following significant improvements were seen following the intervention:

 the proportion of administration forms in which insulin infusion rates were correctly recorded (hourly recording expected) by nursing staff increased from 56% (644/1151) of forms pre-intervention to 69% (455/661) post-intervention (p<0.0002)

 the proportion of administration forms in which the infusion rate was incorrectly documented decreased from 10.4% (120/1151) pre-intervention to 5.6% (37/661) post- intervention (p=0.0004)

 the proportion of administration charts in which the documentation was unclear decreased from 30.9% (356/1151) pre-intervention to 0.9% (6/661) post-intervention (p<0.0002)  the proportion of administration forms in which the infusion rate was missing (hourly

expected recording) decreased from 40.1% (461/1151) pre-intervention to 30.6% (202/661) post-intervention (p<0.0002).

In an audit of subcutaneous insulin administration documentation, the proportion of administration charts with unclear dose documentation decreased significantly from 10.1% (21/208) pre-

intervention to 2.9% (7/245) post-intervention (p=0.0014). There were no significant changes in the proportion of charts with dose incorrectly documented or missing.

This study (Level III-3) provides evidence that form design implemented with staff education can improve the documentation of insulin therapy administration in the acute care setting.

Systems to improve prescription writing