Precision and reliability study of hospital infusion pumps: a systematic review.

BACKGROUND: Infusion Pumps (IP) are medical devices that were developed in the 1960s and generate fluid flow at pressures higher than that of normal blood pressure. Various hospital sectors make use of them, and they have become indispensable in therapies requiring continuity and precision in the administration of medication and/or food. As they are classified Class III (high risk) equipment, their maintenance is crucial for proper performance of the device, as well as patient and operator safety. The principal consideration of the pump is the volume infused, and the device demands great attention to detail when being calibrated. A lack of necessary care with this equipment can lead to uncertainty in volume and precision during the administration of substances. Because of this, it is essential to evaluate its reliability, to prevent possible failures at time of execution. This control aims at the quality of the intended infusion result, becoming an indication of quality. METHODS: This systematic review summarizes studies done over the last 10 years (2011 to December 2021) that address the reliability and accuracy of hospital infusion pumps, in order to identify planning of maintenance and/or other techniques used in management of the equipment. The Prisma method was applied and the databases utilized were Embase, MEDLINE/Pubmed, Web of Science, Scopus, IEEE Xplore, and Science Direct. In addition, similar reviews were studied in Prospero and the Cochrane Library. For data analysis, softwares such as Mendeley, Excel, RStudio, and VOSviewer were used, and Robvis helped in plotting risk of bias results for studies performed with Cochrane tools. RESULTS: The six databases selected produced 824 studies. After applying eligibility criteria (inclusion and exclusion), removing duplicates, and applying filters 1 and 2, 15 studies were included in the present review. It was found that the most relevant sources came from the Institute of Electrical and Electronics Engineers (IEEE) and that the most relevant keywords revolved around the terms ("device failure", "infusion pumps", "adverse effects", "complications", etc.). These results made clear that there remains substantial room for improvement as it relates to the study of accuracy and reliability of infusion. CONCLUSIONS: We verified that the reliability and precision analysis of hospital infusion pumps need to be performed in a more detailed and consistent way. New developments, considering the model and IP specification, are intended, clearly explaining the adopted methodology.

More time in a community setting: A service evaluation of the impact of intrathecal drug delivery systems on place of care of patients with cancer pain.

BACKGROUND: Intrathecal Drug Delivery Systems are underutilised in the management of refractory cancer pain despite evidence of their efficacy. Not all patients who are offered this treatment modality accept it. There is no current evidence that indicates if the use of intrathecal drug delivery systems impacts on place of care for patients with cancer related pain. AIMS: This service evaluation compared place of care, place of death and morphine equivalent daily dose at end of life for patients in whom Intrathecal Drug Delivery was successfully established versus those who chose comprehensive medical management. SETTING/PARTICIPANTS: A retrospective longitudinal cohort study of 45 patients with cancer pain comparing those who had ongoing analgesia successfully delivered via an implanted Intrathecal Drug Delivery System (n = 28) with those who continued to receive comprehensive medical management (n = 17). RESULTS: There was a markedly greater time spent in the community in the intrathecal group than the medical management group (median 126.5vs 25.5 days; p = 0.002) and a lower morphine equivalent daily dose at end of life (median 127.5vs 440.0 p = 0.022). CONCLUSION: In patients with advanced cancer, the successful establishment of intrathecal analgesia is associated with more time in the community and a lower morphine equivalent daily dose at end of life. The study has low numbers, and the sample was retrospectively selected. Nevertheless, these findings suggest the initial investment of time in an inpatient setting may be beneficial. Further research is required, using larger, prospective studies of patient outcomes in this setting.

Loss of effectiveness with an implanted drug delivery system for intrathecal pain therapy due to corrosion.

INTRODUCTION: Intrathecal drug delivery is an established invasive treatment option. Most common complication is catheter malfunction, which can lead to overdose or withdrawal. CASE PRESENTATION: A 61-year-old female patient underwent an elective replacement of an intrathecal drug delivery pump. The patient complained about a loss of effectiveness over the past 2 years. Intraoperatively, a white mass corresponding to morphine precipitation in the pump pocket was found, which appeared to be due to corrosion at the pump-catheter connection site. CONCLUSIONS: Recommendations on how to deal with the decreasing effectiveness of intrathecal drug delivery and on intraoperative catheter handling are provided.

Administering esomeprazole subcutaneously via a syringe driver in the palliative demographic: A case series.

WHAT IS KNOWN AND OBJECTIVE: Proton pump inhibitors are potent suppressors of gastric acid secretion, and are commonly prescribed in palliative medicine. Despite multiple relevant indications in patients at the end-of-life, their use is often precluded as oral and intravenous administration is frequently inappropriate or not possible. Limited anecdotal evidence suggests proton pump inhibitors may be administered subcutaneously. Our objective was to investigate the tolerability and effectiveness of the administration of esomeprazole as a continuous subcutaneous infusion over 24 h via a syringe driver. METHODS: Case series (n = 7) design assessing sequential patients admitted to a specialist inpatient centre for palliative care, who required parenteral proton pump inhibitor therapy. RESULTS AND DISCUSSION: Four patients reported complete resolution of dyspeptic and reflux symptoms post commencement of esomeprazole. Two patients developed upper gastrointestinal bleeding, which via observation of vomitus and stools, resolved with the initiation of esomeprazole. A single patient, deemed high risk of gastrointestinal bleeding, was commenced on esomeprazole and no bleeding events occurred. WHAT IS NEW AND CONCLUSION: Esomeprazole when administered via a syringe driver over 24 h appears well tolerated and effective for the symptomatic management of dyspepsia and treatment of gastrointestinal bleeding. Overall, this series adds to the limited evidence base for using subcutaneous proton pump inhibitors in the palliative demographic.

The Effects of Intravenous Fluid Viscosity on the Accuracy of Intravenous Infusion Flow Regulators.

Intravenous infusion flow regulators (IIFRs) are widely used devices but it is unknown how much the difference between the IIFR scale and the actual flow rate depends on the viscosity of the intravenous (IV) fluid. This study evaluated the effects of viscosity on the flow rate of five IV fluids (0.9% normal saline, Hartmann's solution, plasma solution-A, 6% hetastarch, and 5% albumin) when using IIFRs. The viscosity of crystalloids was 1.07-1.12 mPa·s, and the viscosities of 6% hetastarch and 5% albumin were 2.59 times and 1.74 times that of normal saline, respectively. When the IIFR scales were preset to 20, 100, and 250 mL/hr, crystalloids were delivered at the preset flow rate within a difference of less than 10%, while 6% hetastarch was delivered at approximately 40% of the preset flow rates and 5% albumin was approximately 80% transmitted. When delivering colloids, IIFRs should be used with caution.

Lag times to steady state drug delivery by continuous intravenous infusion: direct comparison of peristaltic and syringe pump performance identifies contributions from infusion system dead volume and pump startup characteristics.

Time lags between the initiation of a continuous drug infusion and achievement of a steady state delivery rate present an important safety concern. At least 3 factors contribute to these time lags: (1) dead volume size, (2) the ratio between total system flow and dead volume, and (3) startup delay. While clinicians employ both peristaltic pumps and syringe pumps to propel infusions, there has been no head-to-head comparison of drug delivery between commercially available infusion pumps with these distinct propulsion mechanisms. We quantified the delivery of a model drug by peristaltic and syringe pumps at clinically relevant flow rates using spectrophotometric absorbance. Delivery curves were modeled and compared, and the time required to reach 5% (T5), 50% (T50), and 95% (T95) of the intended delivery rate was reported. The ability to overcome the combined effects of startup delay and dead volume differed between syringe and peristaltic pumps. T5, T50, and T95 were shorter for the peristaltic pump at higher flow rates. T50 and T95 were shorter for the syringe pump at lower flow rates. The ability to overcome the effects of dead volume was overall similar between the syringe and peristaltic pumps, as was the response to consecutive changes in drug infusion rates. Startup delay and dead volume in carrier-based infusion systems cause substantial time lags to reaching intended delivery rates. Peristaltic and syringe pumps are similarly susceptible to dead volume effects. Startup performance differed between peristaltic and syringe pumps; their relative performance may be dependent on flow rate.

Impact of different syringe pumps on red cells during paediatric simulated transfusion.

BACKGROUND: Critically ill patients frequently need blood transfusions. For safety, blood must be delivered via syringe infusion pumps, yet this can cause red cell damage and increase the rate of haemolysis. AIMS AND OBJECTIVES: To evaluate biochemical and haemolytic markers of red blood cells transfused in three different types of syringe infusion pumps at two different infusion rates (10 and 100 mL/h). DESIGN AND METHODS: A lab-based study using aliquots of 16 red blood cell bags was undertaken. Haemolysis markers (total haemoglobin [g/dL], haematocrit [%], free haemoglobin [g/dL], potassium [mmol/L], lactate dehydrogenase [U/L], osmolality [mOsm/kg], pH, degree of haemolysis [%]) were measured before and after red blood cell infusion and exposure. Three different syringe infusion pumps brands (A, B, and C) were compared at two different infusion rates (10 and 100 mL/h). RESULTS: Total haemoglobin fell significantly in all red blood cell units during manipulation (pre-infusion: 26.44 ± 5.74; post-exposure: 22.62 ± 4.00; P = .026). The degree of haemolysis significantly increased by 40% after manipulation of the red blood cells. Syringe infusion pump A caused a 3-fold increase in potassium levels (3.78 ± 6.10) when compared with B (-0.14 ± 1.46) and C (1.63 ± 1.98) (P = .015). This pump also produced the worst changes, with an increase in free haemoglobin (0.05 ± 0.05; P = .038) and more haemolysis (0.08 ± 0.07; P = .033). There were significant differences and an increase in the degree of haemolysis (P = .004) at the infusion rate of 100 mL/h. CONCLUSIONS: Syringe infusion pumps may cause significant red blood cell damage during infusion, with increases in free haemoglobin, potassium, and the degree of haemolysis. Some pump types, with a cassette mechanism, caused more damage. RELEVANCE TO CLINICAL PRACTICE: In many intensive care units, bedside nurses are able to consider infusion pump choice, and understanding the impact of different pump types on red blood cells during a transfusion provides the nurses with more information to enhance decision-making and improve the quality of the transfusion.

Comparative Analysis of Intravenous Pumps Relocation for Critically Ill Isolated COVID-19 Patients From Bedside to Outside the Patient Room.

OBJECTIVES: To quantify the impact of IV pump relocation for COVID-19 patients from the bedside to outside the patient room on nurse exposure to COVID-19 and conservation of PPE. DESIGN: Original Article. SETTING: Intensive care units at a single-center teaching hospital. PATIENTS: Critically ill COVID-19 patients under contact and special droplet precautions. INTERVENTIONS: Relocation of intravenous pumps for COVID-19 patients from bedside to outside the patient room using extension tubing. MEASUREMENTS AND MAIN RESULTS: The primary objective of the study was to measure the impact of this strategy on COVID-19 exposure, utilizing the number of nurse entries into the patient room as a surrogate endpoint, and extrapolation of this data to determine the reduction or PPE usage. Secondary endpoints included incidence of extravasation, hyperglycemia, hypotension, and diagnosis of CLABSI/bacteremia. A statistically significant reduction in the primary endpoint of the study was observed as room entries prior to pump relocation averaged 15.36 (± 4.10) as opposed to an average of 7.92 (± 2.19) following pump relocation (p < 0.0001). In both pre- and post-pump relocation groups, there was no incidence of extravasation or CLABSI. No significant differences were noted in number of patients experiencing hyperglycemia, hypotensive episodes, or bacteremia. CONCLUSIONS: There was a significant decrease in COVID-19 exposure based on the number of nurse entries following the relocation of intravenous pumps from inside to outside of the patient room. These results may be cautiously extrapolated to suggest a decrease in personal protective equipment utilization. Future prospective, randomized controlled trials investigating the impact of this strategy are required.

Multi-infusion with integrated multiple pressure sensing allows earlier detection of line occlusions.

BACKGROUND: Occlusions of intravenous (IV) tubing can prevent vital and time-critical medication or solutions from being delivered into the bloodstream of patients receiving IV therapy. At low flow rates (≤ 1 ml/h) the alarm delay (time to an alert to the user) can be up to 2 h using conventional pressure threshold algorithms. In order to reduce alarm delays we developed and evaluated the performance of two new real-time occlusion detection algorithms and one co-occlusion detector that determines the correlation in trends in pressure changes for multiple pumps. METHODS: Bench-tested experimental runs were recorded in triplicate at rates of 1, 2, 4, 8, 16, and 32 ml/h. Each run consisted of 10 min of non-occluded infusion followed by a period of occluded infusion of 10 min or until a conventional occlusion alarm at 400 mmHg occurred. The first algorithm based on binary logistic regression attempts to detect occlusions based on the pump's administration rate Q(t) and pressure sensor readings P(t). The second algorithm continuously monitored whether the actual variation in the pressure exceeded a threshold of 2 standard deviations (SD) above the baseline pressure. When a pump detected an occlusion using the SD algorithm, a third algorithm correlated the pressures of multiple pumps to detect the presence of a shared occlusion. The algorithms were evaluated using 6 bench-tested baseline single-pump occlusion scenarios, 9 single-pump validation scenarios and 7 multi-pump co-occlusion scenarios (i.e. with flow rates of 1 + 1, 1 + 2, 1 + 4, 1 + 8, 1 + 16, and 1 + 32 ml/h respectively). Alarm delay was the primary performance measure. RESULTS: In the baseline single-pump occlusion scenarios, the overall mean ± SD alarm delay of the regression and SD algorithms were 1.8 ± 0.8 min and 0.4 ± 0.2 min, respectively. Compared to the delay of the conventional alarm this corresponds to a mean time reduction of 76% (P = 0.003) and 95% (P = 0.001), respectively. In the validation scenarios the overall mean ± SD alarm delay of the regression and SD algorithms were respectively 1.8 ± 1.6 min and 0.3 ± 0.2 min, corresponding to a mean time reduction of 77% and 95%. In the multi-pump scenarios a correlation > 0.8 between multiple pump pressures after initial occlusion detection by the SD algorithm had a mean ± SD alarm delay of 0.4 ± 0.2 min. In 2 out of the 9 validation scenarios an occlusion was not detected by the regression algorithm before a conventional occlusion alarm occurred. Otherwise no occlusions were missed. CONCLUSIONS: In single pumps, both the regression and SD algorithm considerably reduced alarm delay compared to conventional pressure limit-based detection. The SD algorithm appeared to be more robust than the regression algorithm. For multiple pumps the correlation algorithm reliably detected co-occlusions. The latter may be used to localize the segment of tubing in which the occlusion occurs. Trial registration Not applicable.

Effect of warming and infusion of red blood cell concentrates on markers of haemolysis: An ex vivo simulation study.

BACKGROUND: Transfusion of red blood cell (RBC) concentrates is a common procedure to restore blood volume and tissue oxygen delivery in patients with trauma. Although RBC warmers may prevent hypothermia, some warming or infusion equipment may lead to haemolysis and patient injury. OBJECTIVES: The aim of this study was to test the effect of (i) RBC warming and (ii) administration via manual vs. pump infusion on haemolysis. METHODS: This experimental ex vivo study studied haemolysis markers of RBC injury. The sample consisted of 90 RBC infusions in two simulations, randomly, 45 warmed RBC infusions and 45 nonwarmed RBC infusions, in two or three stages: before the intervention (baseline-warming, N= 45; nonwarming, N= 45), after water bath warming at 42 °C (warmed, N= 45), and then after the warmed or nonwarmed RBCs were infused by manual or pump infusion at a rate of 100 mL/h (infusion-warming, N= 45; nonwarming, N= 45). RESULTS: Warmed RBCs showed significantly lower total haemoglobin (Hb) and haematocrit levels and increase in free Hb levels, haemolysis levels, and lactate dehydrogenase (LDH) activity (all p<0.05) than baseline RBCs. Pump infusion RBCs were associated with reduced total Hb and increased free Hb, haemolysis, and potassium (K) levels (all p<0.05) compared with warmed RBCs. In contrast, manual infusion of warmed RBCs resulted in significantly reduced total Hb levels and increased LDH activity (both <0.05). After infusion, total Hb, free Hb, haematocrit, haemolysis, and LDH values were significantly different for warmed vs. nonwarmed RBCs (p<0.05). CONCLUSIONS: Haemolysis biomarkers increase with RBC warming and infusion, especially when using infusion pumps. Critically ill patients should be carefully monitored for possible complications during and after RBC infusion.

Accuracy assessment of bolus and basal rate delivery of different insulin pump systems used in insulin pump therapy of children and adolescents.

BACKGROUND: Continuous subcutaneous insulin infusion (CSII) is commonly used in patients with diabetes. Accurate and reliable delivery by insulin pumps is essential for a safe and effective therapy, particularly when using small doses. In this study, accuracy of bolus and basal rate delivery of various available insulin pumps was evaluated. METHODS: In total, 13 insulin pump systems were tested: eight durable pumps with different infusion sets and one patch pump. Based on IEC 60601-2-24, insulin delivery was measured by recording weight gain of a beaker into which insulin was infused by the pumps. Bolus accuracy was determined by individually weighing 25 consecutive 0.1 or 1.0 U boluses and basal rate accuracy was determined during basal rate delivery of 0.1 or 1.0 U/h for 72 hours. For analyses, basal rate delivery was divided into 1-hour windows and deviation from target was calculated. RESULTS: Regarding different systems, average 0.1 U bolus delivery was -2% to +9% of the intended volume with 53% to 96% of boluses within ±15% of target. During 0.1 U/h basal rate delivery, most pumps showed an initial over-delivery for the first few hours. Three systems reached a total basal rate error <5%; others showed up to +24%. In general, delivery was more accurate when using larger doses. CONCLUSIONS: Considerable differences in insulin delivery accuracy were observed between the tested pumps. In general, when using very low doses, accuracy of insulin delivery is limited in most insulin pumps. This should be considered for CSII therapy in children.

Towards more efficient use of intravenous lumens in multi-infusion settings: development and evaluation of a multiplex infusion scheduling algorithm.

BACKGROUND: Multi-drug intravenous (IV) therapy is one of the most common medical procedures used in intensive care units (ICUs), operating rooms, oncology wards and many other hospital departments worldwide. As drugs or their solvents are frequently chemically incompatible, many solutions must be administered through separate lumens. When the number of available lumens is too low to facilitate the safe administration of these solutions, additional (peripheral) IV catheters are often required, causing physical discomfort and increasing the risk for catheter related complications. Our objective was to develop and evaluate an algorithm designed to reduce the number of intravenous lumens required in multi-infusion settings by multiplexing the administration of various parenteral drugs and solutions. METHODS: A multiplex algorithm was developed that schedules the alternating IV administration of multiple incompatible IV solutions through a single lumen, taking compatibility-related, pharmacokinetic and pharmacodynamic constraints of the relevant drugs into account. The conventional scheduling procedure executed by ICU nurses was used for comparison. The number of lumens required by the conventional procedure (LCONV) and multiplex algorithm (LMX) were compared. RESULTS: We used data from 175,993 ICU drug combinations, with 2251 unique combinations received by 2715 consecutive ICU patients. The mean ± SD number of simultaneous IV solutions was 2.8 ± 1.6. In 27% of all drug combinations, and 61% of the unique combinations the multiplex algorithm required fewer lumens (p < 0.001). With increasing LCONV, the reduction in number of lumens by the multiplex algorithm further increased (p < 0.001). In only 1% of cases multiplexing required > 3 lm, versus 12% using the conventional procedure. CONCLUSION: The multiplex algorithm addresses a major issue that occurs in ICUs, operating rooms, oncology wards, and many other hospital departments where several incompatible drugs are infused through a restricted number of lumens. The multiplex algorithm allows for more efficient use of IV lumens compared to the conventional multi-infusion strategy.

The effect of continuous levodopa treatment during the afternoon hours.

OBJECTIVE: The aim of this retrospective study was to investigate whether patients with Parkinson's disease, who are treated with levodopa-carbidopa intestinal gel (LCIG), clinically worsen during the afternoon hours and if so, to evaluate whether this occurs in all LCIG-treated patients or in a subgroup of patients. METHODS: Three published studies were identified and included in the analysis. All studies provided individual response data assessed on the treatment response scale (TRS), and patients were treated with continuous LCIG. Ninety-eight patients from the three studies fulfilled the criteria. t tests were performed to find differences on the TRS values between the morning and the afternoon hours, linear mixed effect models were fitted on the afternoon hours' evaluations to find trends of wearing-off, and patients were classified into three TRS categories (meaningful increase in TRS, meaningful decrease in TRS, non-meaningful increase or decrease). RESULTS: In all three studies, significant statistical differences were found between the morning TRS values and the afternoon TRS values (P-value <=0.001 in all studies). The linear mixed effect models had significant negative coefficients for time in two studies, and 48 out of 98 patients (49%) showed a meaningful decrease in TRS during the afternoon hours. CONCLUSION: The results from all studies were consistent, both in the proportion of patients in the three groups and in the value of TRS decrease in the afternoon hours. Based on these findings, there seems to be a group of patients with predictable "off" behavior in the later parts of the day.

Comparison of Operator Workloads Associated with the Single-unit Anyfusion® Pump and the Changeover from a Syringe Pump to an Infusion Pump.

BACKGROUND: A changeover from a syringe pump to an infusion pump may transiently interrupt drug administration and result in medication errors. A newly developed infusion device (Anyfusion®) that combines the functions of an infusion pump and a syringe pump in a single unit was recently commercialized. This study compared the operator workloads associated with the Anyfusion® pump and with the conventional method using two infusion devices (a syringe pump and an infusion pump). METHODS: This was a prospective, randomized, crossover-designed simulation study using an imitation arm with an intravascular line. We compared the two methods in terms of total execution time, total number of button clicks, and subjective difficulty using a numerical rating scale with a score from 0 (extremely easy) to 10 (extremely difficult). RESULTS: Twenty-two nurses successfully performed both interventions according to the allocated sequence. Total execution times did not differ between the two methods (129.5 ± 23.2 seconds for the conventional method vs. 121.2 ± 24.3 seconds for the Anyfusion® method; P = 0.244), although the total number of clicks was significantly fewer using the Anyfusion® than the conventional method (median [interquartile range]: 10.0 [9.0-12.0] vs. 21.0 [20.0-25.0], respectively; P < 0.001). Participants rated the Anyfusion® method as easier than the conventional method (1.7 ± 1.2 vs. 3.6 ± 1.6; P < 0.001, respectively). CONCLUSION: The introduction of Anyfusion® lessened the workload of practitioners required by the changeover process, which might reduce the risk of medication errors and subsequent patient harm. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0004172.

Smart pumps improve medication safety but increase alert burden in neonatal care.

BACKGROUND: Smart pumps have been widely adopted but there is limited evidence to understand and support their use in pediatric populations. Our objective was to assess whether smart pumps are effective at reducing medication errors in the neonatal population and determine whether they are a source of alert burden and alert fatigue in an intensive care environment. METHODS: Using smart pump records, over 370,000 infusion starts for continuously infused medications used in neonates and infants hospitalized in a level IV NICU from 2014 to 2016 were evaluated. Attempts to exceed preset soft and hard maximum limits, percent variance from those limits, and pump alert frequency, patterns and salience were evaluated. RESULTS: Smart pumps prevented 160 attempts to exceed the hard maximum limit for doses that were as high as 7-29 times the maximum dose and resulted in the reprogramming or cancellation of 2093 infusions after soft maximum alerts. While the overall alert burden from smart pumps for continuous infusions was not high, alerts clustered around specific patients and medications, and a small portion (17%) of infusions generated the majority of alerts. Soft maximum alerts were often overridden (79%), consistent with low alert salience. CONCLUSIONS: Smart pumps have the ability to improve neonatal medication safety when compliance with dose error reducing software is high. Numerous attempts to administer high doses were intercepted by dosing alerts. Clustered alerts may generate a high alert burden and limit safety benefit by desensitizing providers to alerts. Future efforts should address ways to improve alert salience.

Tracking the Progress of Wireless Infusion Pump Drug Library Updates- A Data-Driven Analysis of Pump Update Delays.

Modern smart infusion pumps are wirelessly connected to a network server for easy data communications. The two-way communication allows uploading of infusion data and downloading of drug library updates. We have discovered significant delays in library updates. This research aimed at studying the drug library update process of one vendor pump and the contributing factors of pump update delays. Our data included BD Alaris™ pump status and infusion reports of two hospital systems (92 and 80 days, respectively, in 2015). We analyzed drug library update progressions at the individual device and fleet levels. To complete a library update, a pump goes through two status transitions: from noncurrent to a new library pending, and from pending to current. On average it took five to nine days for 50% of a pump fleet to become current after a new drug library was disseminated. We confirmed factors that affect noncurrent-to-pending time to include time to first power-on and total power-on time. We also found that high pump utilization promotes shorter pending-to-current time. Two distinctive and important steps of a drug library update on Alaris™ pumps are pending a new library and completing the library installation. To avoid potential patient harm caused by infusion pumps without appropriate drug limits due to update delays, hospitals should monitor the progression of a drug library update on its pump fleet. Potential ways to improve drug library updates on a fleet of pumps include better technologies, improved pump user-interface design, and more staff training.

Opioid Induced Hyperalgesia with Intrathecal Infusion of High-Dose Fentanyl.

INTRODUCTION: Despite being reported since 1943 as well as being the subject of a large body of literature since that time, no consensus has been reached regarding the etiology of opioid induced hyperalgesia (OIH). It is often described as a paradoxical increased pain response to noxious stimuli due to increased sensitization or an acute tolerance to opioids. CASE: We report the case of a 60 year old patient on chronic Intrathecal combined fentanyl and Bupivacaine who had worsening pain with increasing doses and improved after weaning off intrathecal opioids. CONCLUSION: OIH has been described in various settings including patients on methadone maintenance therapy, perioperative opioid administration, cancer patients on opioids, and healthy volunteers who are acutely exposed to opioids, including high dose intrathecal opioids such as Morphine and Sufentanil. To our knowledge, no cases of opioid induced hyperalgesia was previously reported in the case of intrathecal Fentanyl.

Impact of Implementing Smart Infusion Pumps in an Intensive Care Unit in Mexico: A Pre-Post Cost Analysis Based on Intravenous Solutions Consumption.

Background: The use of smart pump technology has shown to be profitable in the intensive care unit (ICU) because it avoids costs from prevented medication errors and allows for savings on disposables and medications by establishing standardized concentrations and dosing units. Objective: The objective of the study is to evaluate the economic impact of the implementation of smart infusion pumps in the consumption of intravenous (IV) solutions in an ICU. Methods: A retrospective observational study was conducted with a pre-post design. The study occurred in the adult ICU of the Hospital Juárez de México. The pattern of consumption of IV solutions (sodium chloride 9%, Hartmann's solution, dextrose 5% and 10%, sodium chloride 0.9% with dextrose 5%) was analyzed preimplementation and postimplementation of 50 Plum A+™ pumps with Hospira MedNet™ security software. Using the TreeAge Pro 2016 software, deterministic and probabilistic analyses were carried out (10 000 Monte Carlo simulations) to confirm the robustness of the annual consumption comparison and the associated expenses before and after implementing smart technology. Results: The implementation of the smart pumps reduced the annual consumption of IV solutions to 8994 units (18%) and 3649 liters (22.3%). In the first year, MXN$55 850.97 were saved. From an institutional perspective and with a probability of 0.63, the use of MedNet™ technology proved to be a lower cost alternative (17.1% saved) with respect to the conventional infusion systems. Conclusion: The implementation of smart infusion pumps allows savings, specifically for the IV solutions used in ICU.

Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

BACKGROUND: Anaesthetic medication administration errors are a significant threat to patient safety. In 2002, we began collecting data about the rate and nature of anaesthetic medication errors and implemented a variety of measures to reduce errors. METHODS: Facilitated self-reporting of errors was carried out in 2002-2003. Subsequently, a medication safety bundle including 'smart' infusion pumps were implemented. During 2014 facilitated self-reporting commenced again. A barcode-based medication safety system was then implemented and the facilitated self-reporting was continued through 2015. RESULTS: During 2002-2003, a total of 11 709 paper forms were returned. There were 73 reports of errors (0.62% of anaesthetics) and 27 reports of intercepted errors (0.23%). During 2014, 14 572 computerised forms were completed. There were 57 reports of errors (0.39%) and 11 reports of intercepted errors (0.075%). Errors associated with medication infusions were reduced in comparison with those recorded in 2002-2003 (P<0.001). The rate of syringe swap error was also reduced (P=0.001). The reduction in error rate between 2002-2003 and 2014 was statistically significant (P=0.0076 and P=0.001 for errors and intercepted errors, respectively). From December 2014 through December 2015, 24 264 computerised forms were completed after implementation of a barcode-based medication safety system. There were 56 reports of errors (0.23%) and six reports of intercepted errors (0.025%). Vial swap errors in 2014-2015 were significantly reduced compared with those in 2014 (P=0.004). The reduction in error rate after implementation of the barcode-based medication safety system was statistically significant (P=0.0045 and P=0.021 for errors and intercepted errors, respectively). CONCLUSIONS: Reforms intended to reduce medication errors were associated with substantial improvement.

Defining electronic-prescribing and infusion-related medication errors in paediatric intensive care - a Delphi study.

BACKGROUND: The use of health information technology (HIT) to improve patient safety is widely advocated by governmental and safety agencies. Electronic-prescribing and smart-pump technology are examples of HIT medication error reduction strategies. The introduction of new errors on HIT implementation is, however, also recognised. To determine the impact of HIT interventions, clear medication error definitions are required. This study aims to achieve consensus on defining as medication errors a range of either technology-generated, or previously unaddressed infusion-related scenarios, common in the paediatric intensive care setting. METHODS: This study was conducted in a 23-bed paediatric intensive care unit (PICU) of an Irish tertiary paediatric hospital. A modified Delphi technique was employed: previously undefined medication-incidents were identified by retrospective review of voluntary incident reports and clinical pharmacist interventions; a multidisciplinary expert panel scored each incident using a 9-point Likert scale over a number of iterative rounds; levels of agreement were assessed to produce a list of medication errors. Differences in scoring between healthcare professionals were assessed. RESULTS: Seventeen potential errors or 'scenarios' requiring consensus were identified, 13 of which related to technology recently implemented into the PICU. These were presented to a panel of 37 participants, comprising of doctors, nurses and pharmacists. Consensus was reached to define as errors all reported smart-pump scenarios (n = 6) and those pertaining to the pre-electronic process of prescribing weight-based paediatric infusions (n = 4). Of 7 electronic-prescribing scenarios, 4 were defined as errors, 2 were deemed not to be and consensus could not be achieved for the last. Some differences in scoring between healthcare professionals were found, but were only significant (p < 0.05) for two and three scenarios in consensus rounds 1 and 2 respectively. CONCLUSION: The list of medication errors produced using the Delphi technique highlights the diversity of previously undefined medication errors in PICU. The increased complexity of electronic-prescribing processes is evident from the difficulty in achieving consensus on those scenarios. Reducing ambiguity in defining medication errors should assist future research on the impact of HIT medication safety initiatives in critical care. The increasing use of HIT and associated new errors will necessitate further similar studies.