A History of Progress with Infusion System Safety

September 2016

Mary Logan

In the opening line of the 2010 report from the first AAMI/FDA summit, we predicted that the legacy of the event would be a more coordinated and focused approach to solving the multitude of challenges associated with drug infusions. Looking back, it was a lucky—or prescient—prediction.

Many of you were inspired and determined to be a part of making change happen, and six years later it’s time to express AAMI’s deep gratitude for your commitment to improving the safety of infusion systems. Let’s look for a moment at some of the progress we've made:

  1. Management of multiple infusions: An AAMI Foundation working group, led by the talented human factors experts at HumanEra, helped develop these nine recommendations for improving multiple line infusions. The AAMI Foundation also hosted a webinar and its leaders spoke at other events about these recommendations. Building on this work, one of four AAMI Foundation “quick guides” that will be coming out soon is about multiple line infusions. Additionally, a toolkit for how to label multiple line infusions based on the HumanEra research is in the works for publication in 2017. 

  2. Standardized approaches to drug libraries and formularies: The American Society of Health System Pharmacists (ASHP), led by subject expert Bona Benjamin, and another AAMI Foundation working group have tirelessly pushed the healthcare community to develop drug libraries that use standardized drug concentrations. Last year, ASHP received a three-year grant from the FDA to develop and implement national standardized concentrations for drug libraries and liquid medications. Also, another AAMI Foundation quick guide will be coming out soon on improving drug library compliance.

  3. Collaboration: In a roundtable discussion published in the fall 2015 issue of Horizons, subject expert and RN Nancy Blake noted that “for the first time that I’ve seen in my career, manufacturers are working with nurses on safety issues. Biomeds, pharmacists, nurses, and especially frontline end users are starting to come together and talk about how pump design can be improved, as well as how end users can use pumps correctly to optimize patient safety.” The original AAMI Foundation working group that started this important collaboration has grown and become the National Coalition for Infusion Therapy Safety. One of the coalition’s deliverables for later this year is a quick guide on questions that C-suite executives in healthcare delivery organizations should ask to assess their organization’s maturity level on infusion safety.

  4. Alarm management: It was clear at the infusion summit that alarm management was a huge issue and, as a result, that topic was the focus of the 2011 AAMI/FDA summit. Fast forward to today and the National Coalition for Alarm Management Safety, spearheaded by the AAMI Foundation, is entering its second phase, and is helping health systems comply with The Joint Commission’s National Patient Safety Goal on clinical alarm safety and become adept at alarm management. The first significant deliverable from the coalition was this practical and essential toolkit. Stay tuned for more from this group.

  5. Collaborative and practical research: In addition to the research on managing multiple line infusions, there were two other significant research projects that added to our practical understanding of clinical workflow around infusion therapy. Most recently, a research paper in the July/August 2016 edition of BI&T summarized the results of the AHRQ-funded project led by a team from Johns Hopkins, using systems engineering expertise from the Johns Hopkins Applied Physics Lab. Last year, the AAMI Foundation reported on the findings from its CareFusion Foundation-funded project led by David Bates, MD, of Brigham and Women’s Hospital.

  6. Shared learning: Earlier this year, the AAMI Foundation and the National Association of Clinical Nurse Specialists (NACNS) launched a series of seminars on what healthcare delivery organizations are doing to raise the bar on infusion safety. The Regenstrief Institute also has an excellent community of healthcare delivery organizations that are sharing lessons learned from their analyses of infusion pump data. And, it goes without saying, the Institute for Safe Medication Practices (ISMP) and ASHP, which were leading this work long before the 2010 AAMI/FDA summit, continue to share the learning from their communities.

In short, working together, the 330 attendees of that first AAMI/FDA summit outlined the primary challenges holding us back with infusion system safety, agreed on the desired future state, and honed in on the key changes that were needed to overcome the obstacles and move us forward. Many individuals have added their contributions to the growing body of knowledge—much more than it would be possible to share in these highlights.

Margaret Mead’s words come to mind with every one of these incremental steps: “Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.” None of this would have been possible without you—the AAMI community—providing leadership, expertise, commitment, time, funding, open minds, and generous spirits.

The greater legacy of that first summit was the re-awakening of the healthcare technology community to the power of AAMI’s convening role. Individually and collectively, you are the power that fuels AAMI’s convening role. Thank you for using that power to improve patient outcomes with infusion system safety.

Kindest Regards,
Mary Logan
Mary Logan, JD, CAE
AAMI President