HTSI

Infusion Systems Working Group Meeting
January 25-26, 2012
Daytona Beach, FL

DAY ONE - January 25, 2012
I. Welcome and Background
The meeting opened with welcome remarks from the Chair of the Infusion Steering Committee, Pat Baird, and AAMI President, Mary Logan. Pat covered "where we started and how far we have come," providing real-life patient stories relevant to our work, outlining the objectives of the meeting, and emphasizing the importance of the discussions. Mary provided an update on the Healthcare Technology Safety Institute (HTSI), its vision, and the role it will play in the outcomes of the infusion systems working group projects.
Background documents:
 
II. Working Group Reports
What We Have Learned Since October 2010: Are We Doing the Right Work?
Working Group Leaders provided summaries of research and working group findings and a brief status report on working group progress since the 2010 Summit. Following each summary, meeting participants had the opportunity to ask questions and engage in discussion about what has been learned and accomplished so far. Meeting participants were also asked to discuss the barriers that all stakeholders face in making progress on infusion system safety, ways to overcome them, and to proceed effectively. (See Meeting Notes for summary of discussions.)
Multiple Line Management, Andrea Cassano-Piche, University of Toronto
 

Drug Library Management, Bona Benjamin, PharmD and Karl Gumpper, RPh, ASHP
 
Integration and Connectivity, Erin Sparnon, ECRI
 
Environment of Use, Joanne Pester-DeWan, PhD, CareFusion
 
Listening Systems/Incident Reporting, Pat Baird, Baxter
 
Standardized Terminology, Pat Baird, Baxter
 
Update on AAMI Standards Activities, Jennifer Moyer, AAMI
 
Information Clearing House, AAMI Staff
 
Alarms Management, James Welch, Sotera Wireless and Tim Vanderveen, PharmD, CareFusion
 
III. Education and Training: What is Needed to Make Education and Training More Effective?
 

Presenters and Topic Leaders:
Glenn Scales, CBET, Duke University Health System
Nathaniel Sims, MD and Rosemary O'Malley, RN, Massachusetts General Hospital
Andrea Cassano-Piche, University of Toronto
  Topic leaders discussed why and how current or traditional methods of education and training on infusion systems need to change and who needs to be involved to change them. Questions explored include: What are the current forms of education and training, who is doing the training, and what is working? Why is "training" a hot issue when it comes to infusion pump systems? Should it be? Do the issues lie in training? Competency? Pump design? Should there be competency standards for clinical staff on infusion systems? What educational tools or systems of communication are needed so that clinical staff are better equipped to program or use infusion systems more effectively? How can we, as working groups, identify and develop recommendations for education?
 
DAY TWO - January 26, 2012
IV. What Can We Learn From the New IOM Report?
  On November 8, 2011, the Institute of Medicine (IOM) released a report that calls for greater oversight by the public and private sectors on the use of information technology in patient care. The IOM finds that safety analyses should not look for a single cause of problems but should consider the system as a whole when looking for ways to make a safer system. Vendors, users, government, and the private sector all have roles to play. Dr. David Bates, a member of the IOM committee that issued the report, discussed what we can learn from it and what impact we can make on safer infusion systems.
 

Presenter: David Westfall Bates, MD, Brigham and Women's Hospital
 
V. What is Research Telling Us and Where are the Gaps?
Intravenous Medical Administration Errors
  In a 2005 article, Marla Husch and others reported on a study conducted at Northwestern Hospital, in which observers on the first shift on a high volume day documented one or more errors in 67% of IV infusions. Ms. Husch and Dr. Bates presented how this study was conducted and the possibility of replicating this study across multiple hospitals.
 
Infusion Pump Vendors Support, Data, and Hospital Partnerships
  Infusion pump vendors support their customers with collection, analysis, and recommendations for improving the use and safety of their 'Smart' pumps. For example, vendors can provide data on alerts logged by smart pumps and the subsequent actions taken by caregivers. Tim Vanderveen reviewed the spectrum of vendor support, vendors' available data, and examples of ways that hospitals and vendors have partnered to use the data. He also discussed the importance of wireless connectivity and the impact it has on data collection.
  Presenter: Timothy Vanderveen, PharmD, CareFusion
Improving User Interfaces
  Awarded a three-year grant by the Agency for Healthcare Research and Quality (AHRQ) to improve the user interface, Alan Ravitz, research study leader, discussed how the Johns Hopkins Applied Physics Lab will adopt a systems engineering approach to prototype pump user interface designs.
 
VI. What Can We Do Now?
Topic Leader: Pat Baird, Baxter
Discussion Leader: John Deadwyler
 

Meeting participants were asked to discuss what the healthcare community can do now to achieve short term successes. the goal was to achieve consensus on:

  • Top 10 actions that the healthcare community can do now to improve infusion systems safety
  • Ways to promote these top ten actions and measure the results .

See Meeting Summary for the working draft of the research agenda and top ten list.
 

The AAMI Foundation would like to thank the following
for their generous support of this meeting: