The devil is in the detail: How a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety

Abstract

Many studies have highlighted the patient safety risks in intravenous medication administration, and various technological solutions have been proposed to mitigate those risks, including ‘smart pumps’ and closed-loop systems. Few studies describe these implementations in detail. In this article, we report on a sociotechnical investigation of a closed-loop documentation system linked with smart pumps for intravenous infusion administration on an intensive care unit. The smart pumps are ‘mapped’ to an electronic prescribing and medication administration system, allowing infusion rates, volumes and boluses of intravenous medication to be monitored in real time. Ethnographic observations were conducted over 37 h, including direct observation of infusion administration (n = 23 infusions), discussions with clinical staff and semi-structured interviews with intensive care unit managers (n = 2). Analysis was based on the Distributed Cognition for Teamwork (DiCoT) method to understand how information is processed across individuals, teams and technologies. We report on how the system works in context, and identify contributions and compromises to patient safety with new risks that need to be managed at bedside and intensive care unit level.

Using FRAM to explore sources of performance variability in intravenous infusion administration in ICU: A non-normative approach to systems contradictions

“…The analysis was complemented by experiences from a previous project DF was involved with that investigated intravenous infusion administration practices and errors in England (e.g. Blandford et al, 2016;Lyons et al, 2018;Furniss et al, 2019a).…”

“…Intravenous infusion administration is a safety critical task that is common in modern hospitals with high levels of discrepancies and errors (Schnock et al, 2017;Lyons et al, 2018). The details and benefits of technological solutions like smart pumps (Schnock et al, 2017;Lyons et al, 2018), closedloop systems (Furniss et al, 2019a) and other forms of automation are being explored (Sujan et al, 2019b). However, recent research suggests that this area is a complex adaptive system where interventions do not have a simple deterministic effect but locally appropriate solutions could improve safety (Blandford et al, 2019).…”

Changes in medication administration error rates associated with the introduction of electronic medication systems in hospitals: a multisite controlled before and after study

“…Understanding the way EMS are used, how, for example, system interfaces and functionality facilitated or inhibited work, and why specific procedures are followed or not is best investigated using qualitative methods. 30 As others have reported, the introduction of medication technologies influences the ways in which work is performed in both expected and unexpected ways. 31 32 Whatever the reasons, our results indicate that introduction of an EMS was not associated with increased compliance with many core medication safety procedures.…”

Direct Observational Study of Interfaced Smart-Pumps in Pediatric Intensive Care

“…This highlights the limitations of comparing simple outcome measures without factoring in particular configurations, processes, and settings. 16,17 Comparison with studies using different outcome measures and methodologies is difficult. A single study in Ohashi et al's 2014 systematic review of smart-pumps was conducted in a PICU; based on a review of CQI data, direct comparison is not possible.…”

“…6,39 There are few published studies looking at these processes, with existing literature either qualitative or based on individual case reports or extracted pump data. 16,40,41 The exploration of autodocumented data are, therefore, particularly valuable. Although rare and potentially serious errors may not have been observed, the low data transfer error rate (1% of observed infusions) and minor clinical significance of assignment and data-transfer deviations is encouraging.…”