Smart infusion technology: a minimum safety standard for intensive care?

There is overwhelming evidence that medication errors present a risk to patients. This risk is highest in the intensive care unit (ICU) setting and even greater when medications are administered via an infusion pump. Standard pumps will not alert for, or prevent, drug calculation, drug unit, button push, or multiple of ten errors when medication delivery data is inputted. However, the literature suggests that smart pumps programmed with hard (unchangeable) limits can significantly reduce drug errors at the point of administration. Staff at St George's Hospital paediatric ICU wanted to implement an infusion pump system that would be immediately effective in reducing medication errors at the point of administration. This article presents an overview of the relevant literature together with clinical examples from the authors' ICU, which demonstrates their experiences with smart pumps. It is the authors' firm belief that smart infusion technology sets a new minimum safety standard for intensive care.

A novel cause of intrathecal baclofen overdosage: lessons to be learnt.

CASE PRESENTATION: A serious intrathecal baclofen overdose occurred in a 45-year-old woman with primary progressive multiple sclerosis following a catheter dye study with concomitant change in baclofen concentration. The pump and catheter were emptied of baclofen 2000 microg/mL, refilled and primed with baclofen 1000 microg/mL. No correction was made for the ;dead space' between the reservoir and catheter access port, which contained baclofen 2000 microg/mL. Failure of the priming bolus to account for the residual baclofen concentration within the dead space resulted in a serious overdose.Action: Amendments are being made to both our local and the Medtronic protocols. CONCLUSION: We hope that by reporting this incident the risk of this potentially fatal error re-occurring is minimized.

Error fatal en prescripción medicamentosa / No disponible

No disponible

Use of personal digital assistants for documentation of pharmacists' interventions: a literature review.

PURPOSE: The literature describing pharmacists' use of personal digital assistants (PDAs) as intervention documentation tools in health systems is reviewed. METHODS: A literature search was conducted using MEDLINE and International Pharmaceutical Abstracts to find articles whose title and abstract indicated that the articles' content addressed pharmacists' use of PDAs as intervention documentation tools. Qualitative analyses were conducted to characterize the existing literature on pharmacists' use of PDAs to document interventions in health systems. The articles were categorized using eight characteristics: study type, objective, setting, participants, PDA platform, documentation software, results, and conclusions. RESULTS: A total of 12 articles were included in this review. All articles were classified as descriptive. Two studies lacked objectives, while 10 contained explicitly stated objectives or objectives that could be inferred from article content. The majority of implementation processes occurred in acute care teaching facilities. All study participants were pharmacists. The majority of articles described PDA-based documentation by more than one pharmacist. Results from the articles can be divided into four categories: no measurable comparison performed, anecdotal comparison performed, survey data reported, and measurable comparison performed. Three articles specifically presented information regarding security and confidentiality of patient information. Each article described the use of password protection for the PDAs. CONCLUSION: The use of PDAs may increase the frequency and number of interventions documented by pharmacists; however, there is a lack of well-designed studies reporting the overall outcomes of using PDAs for intervention documentation by pharmacists.

Use of failure mode and effects analysis in improving the safety of i.v. drug administration.

PURPOSE: Failure mode and effects analysis (FMEA) was used to identify dosing and administration errors associated with i.v. medications and evaluate the effectiveness of subsequent system improvements. SUMMARY: A multidisciplinary medication safety team conducted an FMEA to identify and reduce common medication errors and selected wrong-dose errors for process improvement. In 2002, wrong-dose errors comprised 17% of all medication errors at the hospital (59 of 347 errors). The most common reason for administering the wrong dose was error in programming the i.v. infusion pump (41%). Potential errors (i.e., failures) identified were misinterpretation of the order, removing the wrong medication or wrong concentration of the correct medication, using the wrong diluent or drug to prepare the drip, and entering the wrong concentration or infusion rate on the pump. Errors in programming the i.v. infusion pump was the step in the medication-use process associated with the highest criticality index. Based on the results of the FMEA, two main interventions were performed. First, standard order sets were revised after streamlining the formulary and eliminating the use of unapproved abbreviations. Second, an i.v. pump with enhanced safety features was implemented. One-year follow-up data revealed that the number of medication errors related to dosing (wrong dose or incorrect infusion rate) had decreased slightly (from 59 in 2002 to 46 in 2003); however, a dramatic reduction was noted in the percentage of pump-related errors. In 2003, pump-related errors accounted for 22% of dosing errors, compared with 41% in 2002. CONCLUSION: Medication errors related to i.v. infusion pumps were reduced by conducting an FMEA and implementing the process changes needed.

Potential tenfold drug overdoses on a neonatal unit.

Nearly one third of intravenous drug prescriptions on a neonatal unit were for doses less than one tenth of a single drug vial. Tenfold drug errors in prescribing are well documented and with the continued use of vials containing adult size doses, great potential exists for serious administration errors.

Cladribine underdosing in hairy-cell leukemia: a cause for apparent response failure.

While chemotherapy overdose is often readily discovered, underdosing errors are seldom appreciated. We report two patients with hairy-cell leukemia who apparently failed to respond to cladribine administered by continuous portable pump infusion. It was determined that both patients received one-seventh of the prescribed dose, although the orders were written correctly. The errors resulted in the administration of 1 day's dose over 1 week. The use of 7-day portable pump infusion therapy for cladribine can be associated with misdosing, and is an occult cause of apparent failure to respond in hairy-cell leukemia.