Reducing Infusion Pump Errors
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Reducing Infusion Pump Errors

An error waiting to happen!Copyright 2008

State of the Technology• Pump technology has been relatively stable– rate entered in mL/hr– no feed-back for erroneous programming• Some models can now reduce commoninfusion i hazards– gravity free-flow– dosing errorsCopyright 2008

Free-Flow Flow• Fluid flows freely under the force of gravity whenpump’s p infusion set is removed unclamped• Can occur when infusion set is removed from pump– by a nurse changing patient’s gown clearing air from the set– by the patient or a visitor attempting to stop an alarm• Risk can be greatly reduced by pumps that cause theset to be closed before it can be removedCopyright 2008

IV Medication Errors• Delivery of an incorrect dose– operator incorrectly programs a pump– physician or pharmacist issues anincorrect orderCopyright 2008

IV Medication Errors• Can be reduced d through hseveral strategiest – establish clear protocols for ordering infusions– standardize drug concentrations– use pumps with a dose error reduction system– bar-coding technology (in development) used inconjunction with dose error reduction systemCopyright 2008

Dose Error Reduction SystemDefinition• An advisory function that produces alerts forpotential over- or under-delivery of a selecteddrug or electrolyte• Programmed dose is compared to preset limits• Devices with this capability are being referred toas “smart pumps” and associated with the termsmedication safety or surveillance softwareCopyright 2008

Dose Error Reduction SystemCriteria• System should be able to link drugs, theirconcentrations, dosing units, and dose limitsto ≥8 clinical locations/applications• System should also include maximumpatient weight, VTBI, and rate limit foreach location/applicationCopyright 2008

Dose Error Reduction SystemCriteria• System should permit limits for– manually-entered concentrations– Boluses ouses(volume and time limits)Copyright 2008

Dose Error Reduction SystemCriteria• Soft and hard limits– it should be possible to set limits that canand cannot tbe overridden– it may be desirable to have both for some drugsCopyright 2008

Dose Error Reduction SystemCriteria• System should encourage consistent use– simple to use and few additional steps– usable with minimal-risk i ikif infusionsi• Display should clearly indicate– when the system is not in use– when the pump is operating outside a limitCopyright 2008

Dose Error Reduction SystemCriteria• When the pump is turned on it should–be in dose error reduction system mode–require user to confirm if same or new patientand to select current clinical location/application• Display should identify drug/electrolyteand dose infusing in each channel–TALLman letters (DOPamine / DOButamine)Copyright 2008

Dose Error Reduction SystemCriteria• Multichannel pumps should trigger an alertif same drug is programmed on 2 channels• System should permit batch programmingof facility’s drug library and dose limitsCopyright 2008

Dose Error Reduction SystemCriteria• Pump should have a separate log to record– limit overrides– programming changes that resulted fromlimit alerts• Log should retain data for >1 year and bedownloadable for spreadsheet analysisCopyright 2008

Dose Error Reduction SystemCriteria• Manufacturers should provide facility-basedsupport with implementationti– Coordinate decision-making staff– Develop a drug library consistent with thefacility’s ordering and delivery practices– Develop dose limits and other clinicallocation/application-specific parameters– Train clinicians in the effective use of the pumpand its dose error reduction systemCopyright 2008

Evaluation Ratings• Free-flow protection– Pumps that lack this protection areUnacceptable• Dose error reduction system– Pumps that lack this feature areNot RecommendedCopyright 2008

ECRI EvaluationsGeneral-Purpose Infusion PumpsHealth Devices evaluationOctober 2007Syringe PumpsHealth Devices evaluationJanuary 2008Infusion Pump posterCopyright 2008

Setting Up for Infusion• Use sets and accessories with Luer-lockconnectors for all central venous andarterial lines• Purge air from lines to prevent embolisms,nuisance alarms, and flow errors• Use dose error reduction system on pumpsso-equippedCopyright 2008

During Infusion• To prevent call-back alarms, verify that device isinfusing after starting• Check device operation and IV site as often aswith gravity sets. Occlusion alarms cannot reliablydetect infiltration• Note changes in flow or pressure indicator ifpresentCopyright 2008

During Infusion• Don't repeatedly restart pump after an alarm• Wipe spills off equipment before they dry• Always close manual clamp before removinginfusion setCopyright 2008

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