Right Programming of Pumps to Prevent Errors in the Infusion Process

A Healthcare Failure Mode and Effect Analysis on the Safety of Secondary Infusions

“…The present work agrees with the literature (Flynn et al, 2003;ISMP Canada, 2003;Nunnally & Bitan, 2006;Rothwell, 2009;Squires et al, 2005;Trbovich et al, 2010;Tosha B Wetterneck et al, 2006) in that this type of failure mode is a common risk when using infusion pump technology to deliver intravenous therapy. Programming incorrect infusion parameters is considered high-risk from the HFMEA for all infusion pumps examined since all pumps require manual programming.…”

“…Fail to access Secondary mode M. Nunnally & Bitan, 2006;Rothwell, 2009 Select incorrect drug or drug concentration from drug library Rothwell, 2009; Select incorrect drug library profile Programming primary infusion as a secondary infusion ISMP Canada, 2003;M. Nunnally & Bitan, 2006;Trbovich et al, 2010 Enter incorrect infusion parameters Flynn et al, 2003;ISMP Canada, 2003;M. Nunnally & Bitan, 2006;Rothwell, 2009;Squires et al, 2005;Trbovich et al, 2010; Incorrect calculation Hicks & Becker, 2006;ISMP Canada, 2003;Keay & Callander, 2004;M.…”

“…But before these design changes are implemented, checking the programmed parameters against the physician's order as well as independent double-checks with another nurse may help reduce the likelihood of programming incorrect infusion parameters (Flynn et al, 2003).…”

Adverse events involving intravenous patient-controlled analgesia

“…continuous infusion and intermittent medications in the United States. 3 Errors that occur during the delivery of medication are a frequent cause of preventable adverse drug events (ADEs), which are defined as "injuries resulting from medical intervention related to a drug," 4 and those that involve high-alert medications are of particular concern. Intravenous patient-controlled analgesia (PCA) pumps, which deliver preprogrammed doses of opioid in response to patient activation (depressing a button), mitigate some of the dangers associated with continuous infusion of analgesia and empower patients with control of their pain management.…”

Pca by Proxy

“…Twelve of the 460 errors were attributed to PCA by proxy, with one patient death the result of nurse-activated PCA. 6,8 Error tracking by TJC isn't complete, as it relies on voluntary reporting by hospitals and healthcare practitioners, and estimates of errors may be lower than the actual number of errors.…”