Accidents and Incidents Related to Intravenous Drug Administration: A Pre–Post Study Following Implementation of Smart Pumps in a Teaching Hospital

Guérin, Aurélie; Tourel, Julien; Delage, Emmanuelle; Duval, Stéphanie; David, Marie-Johanne; Lebel, Denis; Bussières, Jean-François

doi:10.1007/s40264-015-0308-6

Cited by 14 publications

(32 citation statements)

References 30 publications

(38 reference statements)

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“…45 Accurate weight scales that only measure in metric units (kilograms or grams), 87 standardized equipment throughout a system, drug dose range limits, programmable "smart" infusion pumps for hospitals, and standardized order sets should be used. 88,89 Drug shortages have recently become an additional safety risk. 90 Clinical pharmacists who are trained in pediatrics are invaluable for medication reconciliation (especially for high-risk children) and may be integrated into inpatient rounds and used for the education of staff and families in all settings as often as possible.…”

Section: Patient Safety Goals and Effortsmentioning

confidence: 99%

Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care

et al. 2019

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Pediatricians render care in an increasingly complex environment, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown since the National Academy of Medicine (formerly the Institute of Medicine) published its report "To Err Is Human: Building a Safer Health System" in 1999. Patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to reveal a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification and diagnostic error. Pediatric health care providers in all practice environments benefit from having a working knowledge of patient safety language. Pediatric providers should serve as advocates for best practices and policies with the goal of attending to risks that are unique to children, identifying and supporting a culture of safety, and leading efforts to eliminate avoidable harm in any setting in which medical care is rendered to children. In this Policy Statement, we provide an update to the 2011 Policy Statement "Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care." BACKGROUND INFORMATION Patient safety is defined as the prevention of harm to patients. 1 Although patient safety is only 1 of the 6 domains of quality of care defined by the National Academy of Medicine (formerly the Institute of Medicine [IOM]), 2 it is undoubtedly one of the most important. There are real and growing concerns regarding pediatric errors and harms reported related to specific populations, such as with the use of temporary names in newborn care, 3 as well as issues spanning all populations, such as diagnostic errors in ambulatory and hospital settings 4 and information technology errors in prescribing. 5 Pediatricians in all practice settings can help champion the

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Section: Patient Safety Goals and Effortsmentioning

confidence: 99%

Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care

et al. 2019

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“…Therefore, our findings need to be confirmed in multiple hospital settings, to enable generalization, and more studies of IPISs are needed. In most countries where IV preparation errors were reported, ready-to-use IV bags, eMARs, and smart pumps with bar codes are not in common use yet [12,13,[22][23][24][25][48][49][50][51][52][53][54]. However, these systems will likely be implemented in the future.…”

Section: Study Limitationmentioning

confidence: 99%

Evaluation of an intravenous preparation information system for improving the reconstitution and dilution process

Shin

Lee

et al. 2016

International Journal of Medical Informatics

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“…Some studies have demonstrated smart pump technology has intercepted potentially serious medication errors, significantly decreased reported errors and reduced costs associated with IV infusions . Other studies have shown no meaningful reduction in serious medication error rates since the implementation of smart pumps …”

Section: Introductionmentioning

confidence: 99%

Reducing intravenous infusion errors: an observational study of 16 866 patients over five years

Poole

Ahlin

Dooley

2018

Pharmacy Practice and Res

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Background Medication administration errors account for the largest proportion of medication errors in hospitals, impacting significantly on patient safety. Intravenous infusions carry a high risk for error due to their complex nature and use in high acuity settings. Two safety strategies for infusion safety introduced across a tertiary hospital network include the utilisation of the clinical pharmacy review and annotation of infusion orders, and the introduction of smart infusion pump technology with dose error reduction software. Aim The objective of this study was to evaluate the effects of two medication safety strategies: clinical pharmacist review including medication order annotation, and introduction of smart infusion pumps on rate and severity medication administration errors. Method A pre‐ and post‐intervention, observational study was undertaken at four time points over a five‐year period which included the review of 16 866 patients in a large tertiary referral hospital. Results Pharmacist annotation independently resulted in a reduction in errors from 16.6 to 8.1%. Subsequent implementation of smart pumps with a comprehensive drug library and high user compliance resulted in a further reduction from 8.1 to 3.9%. These reductions were sustained, with an overall error rate of 5% after two years. Conclusion The importance of timely clinical pharmacist review of intravenous infusion medication orders, and the implementation of smart infusion pump technology, along with well‐resourced drug library development with emphasis on quality management, education and training, should be prioritised, in order to reduce medication administration errors and to maximise patient safety.

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Accidents and Incidents Related to Intravenous Drug Administration: A Pre–Post Study Following Implementation of Smart Pumps in a Teaching Hospital

Abstract: We observed no risk reduction associated with the implementation of smart pumps in a 500 bed mother-child hospital. Further studies are required to explore the details of the potential risk reduction associated with the use of smart pumps.

Cited by 14 publications

References 30 publications

Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care

Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care

Evaluation of an intravenous preparation information system for improving the reconstitution and dilution process

Reducing intravenous infusion errors: an observational study of 16 866 patients over five years

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