Episode #146 A Smart Way to Keep Patients Safe from Medication Errors

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We have spent the last few weeks discussing many of the excellent articles from the February 2023 APSF Newsletter. For the show today, we are going to go back in time to review an article from our archives!

Before we dive into the episode today, we’d like to recognize ICU Medical, a major corporate supporter of APSF. ICU Medical has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, ICU Medical – we wouldn’t be able to do all that we do without you!”

We have talked about the intersection between anesthesia patient safety and technology before on this podcast. This is such an important topic especially since providing anesthesia care involves the use of various pieces of technology. Our featured article highlights technology that anesthesia professionals use regularly. It is “How Can We Tell How “Smart” Our Infusion Pumps Are?” by Vanderveen, O’Neill, and Beard from the February 2020 APSF Newsletter. To follow along with us, head over to APSF.org and click on the Newsletter heading. From here, fifth one down is the Newsletter Archives. Then, click on February 2020 and scroll down until you find our featured article. I will include a link in the show notes as well.

Before we even get into the article, the Editor included a note that provides a link to the ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps for more information. I will include the link in the show notes. Plus, while you are over at website, you can check out some of the more recent articles from the ISMP. In October 2022, the ISMP published the article, “Safety Considerations for Challenges When Using Smart Infusion Pumps.” The article provides an update on some of the challenges that health care professionals face when using smart infusion pumps related to optimizing drug libraries and implementing safeguards to prevent medication errors that put patients at risk. And don’t worry, I will include a link to this updated article in the show notes as well.

Our featured article today about Smart Infusion Pumps fits into APSF’s Perioperative Patient Safety Priorities. Check out #7 which is Medication Safety which includes drug effects, labeling issues, shortages, technology issues, and processes for avoiding and detecting errors. I will include a link to the APSF Patient Safety Priorities in the show notes. We hope that your department or institution or even your practice recognizes how important medication safety is for keeping patients safe during anesthesia care.

Now, it’s time to get into the article. Remember, this is an article from our archive’s episode. Things may have changed since the article was published, but it is of interest from our archives.

Did you know that medication errors are a leading cause of patient harm in the hospital and operating rooms? The majority of medication errors, over 50%, may lead to patient injury from the medication administration. There are different ways to administer medications including by bolus administration or by an infusion. In the past, infusion devices were designed to infuse intravenous medications over a certain time or at a certain rate. Smart infusion pumps have additional smart features which provide clinical decision support tools to help with the medication administration process. Some of these smart features include minimum and maximum dose alerts, concentration, duration, and rate alerts, and includes dose error reduction software. This technology can help to keep patients safe by preventing programming errors such as typing 50 mgs instead of 5mgs.

Smart infusion pumps with drug libraries may be used when providing anesthesia care and throughout the perioperative period. In 2005, only 35% of hospitals reported using smart infusion pumps, but by 2017, the American Society of Health System Pharmacists reported that 88% of hospitals were using smart infusion pumps.

Medication errors are a big threat to patient safety and remain a focus for the APSF. In 2010, the APSF sponsored a medication safety conference with the goal to develop new strategies to improve medication safety in the operating room. The meeting highlighted the importance of the following ideas: Standardization, Technology, Pharmacy/Prefilled/Premixed, and Culture. The key recommendations included the following:

1. ensuring that all medication and fluid infusions are administered via a smart infusion device
2. facilitation of adequate training and improved standardization of smart infusion pumps

Eight years later, the 2018 APSF Stoelting Conference focused on medication safety and recommended the development of consensus between professional and patient safety organizations on standardization of drug concentrations used in infusion administration. Do you have standard drug concentrations used in the infusions at your institution? This standardization of drug concentrations is an important step for improved patient safety.

Next up, let’s talk about the challenges and barriers to successful adoption and use of smart pumps.

First, there are usability and workflow barriers which involves either not using the smart infusion pumps or incorrect use of the pumps leading to an increased risk for medication errors. Anesthesia professionals may think that they can safely infuse medications the way they have done it in the past without the smart pumps or by bypassing the dose error reduction software. Almost all infusion pumps used in the acute care setting today have drug error reduction software, but it is possible to bypass this key decision support tool. Noncompliance is likely driven by outdated interfaces and the ability to easily bypass the drug error reduction software programming. Going forward, it is critical to understand the barriers to compliance with this decision support tool when evaluating the impact of smart pumps on patient safety.

Another barrier involves building and then maintaining the custom drug libraries which then set the appropriate limits in the drug error reduction software and this step may need to be built from scratch. There are several components of the library: the included medications plus the safety alert thresholds for dose, concentration, and duration and rate alerting. This process requires time and resources just to set it up and then there is an additional time and resources requirement to maintain and update the library to ensure optimal results, compliance with smart pump use, and improved patient safety.

The third barrier is alarm and alert fatigue. Just like other health care technologies, excessive alerts or alarms may compromise patient safety if the health care provider experiences alarm or alert fatigue.

So, what can be done about these barriers to adoption of smart pumps during anesthesia care? We need to look at a success story for an example. The APSF described what Wake Forest University Baptist Medical Center did back in 2010 to standardize infusion-related practices across multiple patient care areas including the operating rooms. Here are the interventions that led to the successful implementation.

• Multidisciplinary engagement incorporating pharmacy, nursing, intensive care providers, and anesthesia professionals
• A focus on standardization of all IV medications concentrations, dosing units, and adoption of smart pump technology across the continuum of care in the organization
• An emphasis on training staff to ensure there was an understanding of the capabilities and limitations of the infusion devices

Do you have smart infusion pumps at your institution? How smart are they? Infusion pumps may be able to collect information during use including discrete keystroke data and information about clinicians responses to alerts. This information can be sent wirelessly to a central server. The problem from here is that the data may be difficult to access and interpret and may not be used by clinicians who are in charge of these devices. In 2018, the Institute for Safe Medication Practices, or ISMP, completed a survey to determine if the smart pump data analytics were being used by pharmacists and nurses at 126 hospitals. The results showed that 96% of the respondents believe that the data from the smart infusion pumps was critical for quality improvement. However, only 22% of respondents felt that their organization had the resources and skills to take appropriate action to ensure smart use of the smart pumps. Following this study, the ISMP recommended that organizations used data companies or infusion pump manufacturers to help evaluate the data.

What information is captured in infusion devices? Data may be collected related to the clinician deciding to use the drug error reduction software or a “no drug selected” or “basic infusion” mode and reported as the percentage of infusions using the software. Keep in mind that anytime the drug error reduction software is bypassed, there is no clinical decision support or safety limits during the infusion, and this is a threat to anesthesia patient safety. This data is important so that the smart pump infusion users, the clinicians, can better understand how often programming errors occur and how often the software is bypassed. This feedback supports continuous quality improvement.

Additional data may be collected related to alerts and alarms. Alarm fatigue occurs when clinicians are desensitized to alerts or alarms due to the occurrence of clinically meaningless alerts which then leads to missed important clinical alerts, delayed assessment of patients, and the potential for serious patient harm. Infusion pump logs may be able to capture each alert as well as the clinician’s response. This data may be used to evaluate alert management and reduce fatigue. Clinical alerts may include the following: minimum and maximum alerts for dose, concentration, and duration or rate alerts. Clinician responses to these alerts may include overriding an alert and proceeding, cancelling the infusions and preprogramming as a basic infusion, or altering the infusion parameters to be within the alert limits. Reviewing alert data may be helpful to decide if any of the limits need adjusting or if there are any potential unsafe practices related to specific medications.

In 2015, the national, interprofessional Standardize 4 Safety Campaign kicked off by the ASHP to help decrease medication errors by standardizing medication concentrations. This standardization requires the following information:

1. the overall usage of specific agents
2. the location where these medications are administered
3. the dose and concentrations that were commonly used
4. the total volume administered.

The authors provide the example of evaluating infusion pump data in anesthesia care areas to determine commonly used medications and their concentrations. Another important consideration is the standardization of concentrations and dosing units between anesthesia care areas including the operating room and inpatient units and the intensive care unit to decrease the risk for medication errors when patients are transferred to different areas of the hospital.

Let’s take a look at Figure 1 from the article which highlights smart pump considerations for anesthesia professionals. I will include this in the show notes as well.

• Dose Error Reduction Software (DERS) should be utilized for all medications administered via an infusion pump
• Anesthesia and Pharmacy should collaborate on the following:
  • Build of the Anesthesia medication drug library
  • Periodic review of the anesthesia medication alert and alert response data
  • Maintenance and modification to drug library
  • Assessment of medication usage patterns when drug shortages occur
  • Review of appropriate preparation and dispense volume for controlled substances
  • Evaluate dispensed versus administered drug amounts for “right sizing” to prevent waste
• Ensure that standard concentrations and dosing units exist between the perioperative anesthesia and critical care areas

Another consideration for smart pump infusion data is the report the total volume of the infusion administered to a patient to help determine the appropriate amount of drug infusion to dispense. This data may provide a more precise measurement for how much medication was administered to the patient instead of relying on manual calculation by the clinician or review of the electronic health records.

Another consideration for smart infusion pump use is to help decrease narcotic diversion. The ASHP recommends implementing a surveillance program which can be used to monitor data from medication technologies in high-risk areas including the operating room. A narcotic diversion monitoring program can monitor how much drug is dispensed from the pharmacy compared to how much is administered to the patient and how much is wasted. Infusion pump data provides the exact amount of drug administered to the patient. It is important to account for unused medication that could be diverted so that it is safely wasted. In addition, minimizing opioid dispensing can further help to decrease opioid-related complications in other patient care settings.

One more consideration for smart infusion pumps is to help keep patients safe from medication errors in the face of drug shortages, which may impact up to 63% of injectable medications. This is a threat to patient safety when clinicians may need to use less familiar alternative medications. Smart infusion pumps may help to conserve drug supply during a shortage by providing information about the drugs and amount of drug being administered to patients.

As we wrap up for today, the authors leave us with important considerations going forward when using smart infusion pumps with the safety features to help keep patients safe from medication errors. Optimizing smart pump technology requires management of dispensed container volumes, opioid diversion, and drug shortage management. There is a call to action for a multidisciplinary team to build effective anesthesia drug libraries, standardize infusions, and engage in continuous data analysis to maximize the effectiveness of the smart infusion pumps and decrease medication errors.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2023, The Anesthesia Patient Safety Foundation