Programmable Infusion Pumps In ICUs: An Analysis of Corresponding Adverse Drug Events
Nuckols, T. K., Bower, A.G., Paddock, S.M., Hillborne, L. H., Wallace, P., Rothschilde, J.M., Griffin, A., Fairbanks, R.J., Carlson, B., Panzer, R.J., & Brook, R.H. (January 2008). J Gen Intern Med, 23 (Suppl 1), 41–45. Published online 2007 December 19. doi: 10.1007/s11606-007-0414-y; PMCID: PMC2150642
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150642/
http://www.springerlink.com/content/ax85931168450846/fulltext.pdf
Abstract
Background: Patients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable.
Objectives: To determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software (“smart pump”) and to suggest potential improvements in smart-pump design.
Design: Using retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges.
Participants: 4,604 critically ill adults at 1 academic and 1 nonacademic hospital.
Measurements: Preventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs.
Results: Of 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps’ capabilities might enable them to prevent more IV-ADEs.
Conclusion: The smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.