Tubing Misload Allows Free Flow Event with Smart Intravenous Infusion Pump

Human factors systems approach to healthcare quality and patient safety

“…The lack of attention to HFE in the design, implementation, and use of health IT contributes to limited success of health IT, the failures to implement and sustain health IT, and safety problems linked to health IT (Karsh et al, 2010). Our research has examined the impact of health IT on work system and patient safety in a variety of domains: BCMA technology in hospital settings (Carayon et al, 2007b; Koppel et al, 2008), smart infusion pump technology in a hospital (Carayon et al, 2010; Schroeder et al, 2006; Wetterneck et al, 2006), and CPOE/EHR in ICUs (Carayon et al, 2011c; Hoonakker et al, 2010; Hoonakker et al, 2011; Wetterneck et al, 2011). We have also used the SEIPS model to classify self-reported facilitators and barriers to physicians’ use of implemented CPOE/EHR (Holden, 2011c) and to improve the design of a clinical decision support for primary care physicians (Hoonakker et al, 2012).…”

Sociotechnical systems approach to healthcare quality and patient safety

“…A reason for the limited success of health IT, the failures to implement and sustain health IT, and safety problems linked to health IT is the lack of attention to HFE in the design, implementation and use of health IT. Our research has examined the impact of health IT on work system and patient safety in a variety of domains: bar coding medication administration technology in hospital settings [14, 27], smart infusion pump technology in a hospital [10, 32, 39], and CPOE/EHR in ICUs [6, 23, 24, 41]. …”

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology

“…Five of the problems were not anticipated by the FMEA team during failure-mode generation, including three free-flow events, one of which was related to tubing misplacement. 36 Two problems were related to unintended consequences of implementing the new i.v. pump (loss of rate-taper function and incompatibility of tubing with a desired needleless injection port).…”

“…The inclusion of engineers was previously reported to encourage infusion pump redesign and was important with our own redesign issues. [36][37][38][39] It is important for hospitals to be able to judge the success of their FMEA efforts and learn from the process. FMEA is very time-consuming and resource-consuming for a hospital, 21,26 so the return on this investment must be measured.…”