Pharmacy Informatics Health Information and Reaction
Topic: #8 Smart Pump Optimization
Barzaga, Camila D. College of Pharmacy, St. Dominic College of Asia
Part I: Summary
Part II: 1st reaction
A Report on Smart Pump Optimization
Intravenous (IV) infusion pump systems are one of the most widely utilized
medical technologies. Infusion pumps are used by an estimated 90% of
hospital patients, demonstrating how common these devices are in patient
care, particularly in critical and acute care settings. Clinical use of IV smart
pumps with built-in dose error reduction systems (DERS) began at
Massachusetts General Hospital in 1996 and has since become widely
accepted as a standard of care for the reduction of infusion-related
medication error. Although the use of IV smart pumps has been linked to a
reduction in drug errors, they have not completely eradicated them.
Furthermore, there is no evidence that the use of IV smart pumps has
resulted in a significant reduction in adverse medication events (ADEs).
Overriding dosage error notifications and, even more serious, manually
circumventing the drug libraries and DERS are also common sources of user
mistake. Nurses typically cite the difficulty of the device user interface, the
time necessary to set up the DERS, and inadequate drug libraries as reasons
for bypassing IV smart pump safety safeguards. The complexities of IV
pharmaceutical administration, as well as the numerous stages required,
necessitate meticulous attention to detail, and rely primarily on
human–device interaction to detect and minimize mistakes. During IV smart
pump programming, clinicians in hectic critical care and medical-surgical
settings are constantly distracted and rushed. As a result, due to time
constraints and conflicting job demands, overriding of alarms and
programming outside of the DERS is now accepted as standard clinical
practice. Despite an increased focus in health care on patient safety and
quality of treatment, as well as technological advancements, drug mistakes
and usability concerns with IV smart pumps constitute a major patient safety
concern.
More than 23,000 reports of failure and injury for the three most widely used
high volume IV smart pumps were filed to the US Food and Drug
Administration (FDA) Manufacturer and User Device Experience database
from 2015 to 2017. (Alaris, Baxter, and Hospira). The widespread use of IV
smart pumps, combined with a sense of urgency to solve IV medicine safety,
has drawn the attention of various patient safety groups. IV medicine
delivery is a multistep, complex procedure with several potential for
mistakes, with administration at the point of care being the most susceptible
element of the procedure. Medicine error is a broad term that refers to a
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 variety of ways in which IV infusions can go wrong at any point throughout
the medication delivery process. Six elements of the process were identified
during a failure modes and effects analysis of the set of processes used to
deliver continuous drug infusions at an 11-bed pediatric ICU: (1) selecting
the drug, (2) selecting a dose, (3) selecting an infusion rate, (4) calculating
and ordering the infusion, (5) programming the infusion pump, and (6)
delivering the infusion.

2nd reaction Since evidence shows that the majority of ADE are caused by erroneous
programming, programming mistakes are known to lead to medication
mistakes using IV infusion pumps. Incorrectly entering (or selecting from
menus of) drug names, doses/concentrations, rates, and times; bypassing the
drug library (either accidentally or intentionally); and administering an
incorrect or unauthorized medication, as well as overriding drug limits or
alerts are all examples of programming errors. Incorrect clinical judgments,
mental computation mistakes, typing mistakes, and usage problems
connected to the infusion device interface can all result in programming
problems (eg, entering information into the wrong field). Multiple IV
infusions, secondary infusions, IV boluses, and titrated doses are especially
vulnerable to mistakes. Multiple infusions put extra cognitive strain on
doctors, are not well-standardized, have several failure mechanisms, and
mistakes are difficult to identify. The most frequent way for providing IV
drugs intended for one-time or intermittent dosing, notably IV antibiotics, is
through secondary infusion.

3rd reaction The secondary administration is intended to allow the initial continuous
infusion to resume after the secondary infusion is finished. Most IV smart
pumps (with the exception of the Hospira Plum series) require the nurse to
manually increase the secondary IV bag height to ensure that the secondary
hydrostatic pressure differential is large enough to prevent the primary
infusion from flowing until the secondary has completely infused. If the bag
height discrepancy is insufficient to prevent the initial infusion from
flowing, the secondary may not infuse at all, or both bags may infuse at
different rates. Even if the pump is properly programmed, this can happen.
In either case, a medicine delivery mistake occurs, which is rarely
recognized or reported. Most IV infusion pumps require a bag height
differential, the complicated acute care setting, the high cognitive load
necessary for IV medicine delivery, and a high frequency of interruptions.
Increased human error during secondary medicine delivery is due to a lack
of standardized training and education about the relevant principles for
secondary infusions, as well as a lack of standardized training and education
about the relevant principles for secondary infusions.

Concluding Paragraph There is a definite demand for IV smart pump innovation to address
usability and safety issues. Although some of the concerns may be addressed
by changes in clinical systems, the most basic difficulties require innovation

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 and the creation of new technology utilizing a human factors approach.

References:
[1] Carayon P, Hundt AS, Wetterneck TB. Nurses’ acceptance of Smart IV pump technology. Int J Med
Inform 2010;79(6):401–11.
[2] Giuliano, K. K. (2018). Intravenous smart pumps: usability issues, intravenous medication
administration error, and patient safety. Critical Care Nursing Clinics, 30(2), 215-224.