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Hospital meets challenge of new IV medication delivery system technology
All averted errors captured by system
The big challenge for Women and Children's Hospital-Kaleida Health of Buffalo, NY, was using new IV medication delivery technology for patients that ranged from premature infants to geriatric adults.
"We needed an IV pump that would address our entire spectrum of patients, and the new pump wasn't very useful for pediatrics at first, so we leveraged it to make it pediatric-friendly," says Michael A. Cimino, MS, RPh, clinical pharmacy services manager at Women and Children's Hospital.
The process took several months, and it required flexibility on the part of the pump's manufacturer, who made a number of infrastructure changes to accommodate the hospital's needs.
Often, when new technology is blocked by old processes or specialized needs, the solution is work-arounds where hospital staff bypass some of the technology's functions to adjust it to suit their patients' specific needs. But this can increase the risk of medication errors, Cimino notes.
"So we wanted to approach the problem directly and have the programming designed specifically for pediatrics, while recognizing the fact that in other parts of our hospital, it also could be used for different populations," he says.
Here's how hospital pharmacists and others met the challenge:
Build flexibility into IV pump's library:Pharmacists can program the pump's drug library with doses in a range that is applicable for a particular population. For instance, the Women and Children's Hospital needed to have doses for premature neonates all the way to adults, but these needed to be segregated by hospital area so there would be no mistake of adult doses being administered to children or babies, Cimino explains.
"If this pump was going to be used in the ob/gyn area, then you could pick a category for the pump so you'd have access to the library specific to that population," he says.
Cimino assigned a pharmacist clinical coordinator to the job of programming the pump's library with appropriate dosage ranges.
Use a multidisciplinary team approach to improving process: "We had assistance from the pump manufacturers, and this was a multidisciplinary process that involved pharmacy, nursing, medical staff, ISP, and medical engineering," he adds.
"We used the pumps, trying them out and identifying problems," Cimino says. "And this had a benefit in terms of implementation."
Each time the team made improvements to the IV pump process, various end users would try out the changes and report back with suggestions until they were satisfied, he says.
"This is in contrast to other situations where technologies are introduced with minimal education and end-user input and satisfaction," Cimino says. "End users include physicians and others who rely on this technology either directly or indirectly."
Often the end result is that employees have difficulty using the new technology, and the acceptance rate is low.
"This process went very smoothly with a high rate of acceptance because of iterations of trials," Cimino says. "We kept going through the process of identifying problems and addressing them to get to the point where all end users were happy with it."
Solve workflow problems through trials and improvements: Some workflow issues are difficult to anticipate, so they are discovered only through a trial or testing process.
For example, the new IV pump's information screen was too small for the multidisciplinary care team to read from 10 to 15 feet away as they conducted patient rounds, Cimino says.
"If they can't see the rate or dosage, then someone has to walk over there to read it," he adds.
Physicians didn't like this inconvenience, so pharmacists asked the manufacturer to change the size of the screen and its writing so that it could be seen from 10 feet away. The manufacturer made the changes, and physician satisfaction increased with the new technology, Cimino says.
Another workflow problem involved the touch screen's reprogramming process.
When nurses needed to reprogram the touch screen to change the dosage, they had to touch 4-5 different screens before reaching the correct one, says Kelly Michienzi, PharmD, clinical coordinator.
"It took them too long," she says. "We had hot buttons added to the touch screen so they can quickly titrate doses without going back to the main menu to reprogram dosages."
With the new hot button, nurses can make changes with one touch.
Since one of the hospital's goals was to program the IV pumps for use in pediatrics, they added dosing units for a pediatric population, Michienzi notes.
As a safety measure, this meant the maximum dosage needed to be changed so nurses couldn't exceed the usual adult dose, she explains.
"On the first version of the old pump software, you could pick one or the other, and if a patient was a large individual, you could program it to give a bigger dose than the usual adult dose, Michienzi says.
As nurses and pharmacists worked with the new technology, they found they wanted better and longer descriptions in drug naming.
"If you use a drug for more than one indication, you need to be able to put it in twice with more description," Michienzi says.
For example, the drug naloxone could have two different dosages based on the indication.
"If the indication is for narcotic reversal, then you would use a high dose," Michienzi explains. "If the indication is just because of a side effect of itching then the patient needs a low dose."
In the old version, nurses would just see the word "naloxone" on the pump. After making the change, this became "naloxone-overdose" or "naloxone-pruritus," she adds.
This change also improved patient safety by making it less likely someone would accidentally give a patient a high dose of naloxone when they needed a low dose for treating itching.
This long trial and improvement process eliminated the need for staff to do work-arounds with the new technology, Cimino notes.
"We addressed how the normal workflow for a nurse would occur," he says. "So there was very little need to do work-arounds, and the equipment was user-friendly."
The changes they made followed the normal logic and flow of end-users' work process.
Measuring outcomes more efficiently: Hospitals and pharmacy departments want to measure medication errors and safety improvements, but self-reported methods often greatly under-report errors.
The IV pump technology could automatically track and report all prevented medication errors. When someone attempted to administer a medication at the wrong rate or wrong dose, the machine captured this information. And it was captured anonymously, so mistakes couldn't be tracked back to the person who made the error. This proved to be a much more efficient way to track prevented medication errors.
The Women and Children's Hospital found that the voluntary medication error reporting system only identified 4.6% of all prevented errors, Cimino says.
"Our incidence reporting system was bad at identifying and reporting, as compared with the electronic method of identifying errors," he adds.
While everyone has a responsibility to voluntarily report medication errors, there are several barriers to their doing so: first, there is the fear of reprisal; secondly, they might fix the error, see that nothing bad has happened to the patient, so they rationalize that it's okay to not report it, Cimino explains.
"If a person is afraid that reporting an error will impact someone's employment and the hospital has a punitive system, then they'll fix the problem but not report it," he says.
Third, even if a hospital has a mandatory reporting policy, staff will find ways around it because this is a very time-consuming process. And, fourth, even if a hospital employee is well-intentioned and takes time to report all medication errors for a week, the next week the person's workload might be so significant that fewer errors are recorded.
This leads to an inherent variability in reporting errors, Cimino says.
"It might take a significant amount of time to report errors, and how will people get their work done if adequate resources are not allocated to that activity," Cimino says.
Another benefit to having the new technology track medication errors was that the very process of tracking the errors led to a reduction in errors.
In data collected over one 12-month period, Cimino found that from the baseline of the first weeks after the IV pump's implementation to the end of the first year of its use, prevented medication errors dropped by almost 50%.
"This was a user-friendly pump, so there weren't that many pump errors because of staff's unfamiliarity with the technology," Cimino notes.
The point is that hospitals always have difficulty tracking potential medication errors unless they have a technological solution to tracking the information, he adds.