"Smart" infusion pumps join CPOE and bar coding as important ways to prevent medication errors

From the February 7, 2002 issue

Computerized prescriber order entry (CPOE) and bar code applications for drug dispensing and administration represent technologies that are capable of reducing medication errors. Unfortunately, most hospitals have not yet implemented these systems, so many errors that otherwise might be eliminated continue to put patients at risk. Yet, even if these technologies were fully installed, serious errors are still possible, especially with IV "high alert" medications. Even if the right drug and dose are at hand, a misprogrammed infusion pump can leave a patient only a button press away from disaster.

A new technology has emerged and already it's beginning to play a role in risk reduction. Infusion systems, such as those from Alaris Medical Systems (MEDLEY) and Baxter Healthcare Corporation (COLLEAGUE CX), allow hospitals to enter various drug infusion protocols into a drug library with pre-defined dose limits. If a dose is programmed outside of established limits or clinical parameters, the pumps halt or provide an alarm, informing the clinician that the dose is outside the recommended range. Some pumps have the capability of integrating patient monitoring and other patient parameters such as age or clinical condition. Other manufacturers are bringing similar devices to market.

Recently, a physician in the emergency department wrote an order for INTEGRILIN (eptifibatide) but inadvertently prescribed a dose appropriate for REOPRO (abciximab). The Integrilin infusion was initiated and continued for approximately 36 hours after the patient was transferred to a medical/surgical unit. During this time, the patient's mental status was deteriorating. At this point, the hospital was switching to the Alaris Medley system which performs a "test of reasonableness" before allowing the infusion to begin. As the nurse was transferring the infusion parameters from the old infusion system to this new system, safety software incorporated in the device alerted the nurse that there was a "dose out of range." The pump would not allow the nurse to continue until a pharmacist was called and the mistake was corrected. In another case, a hospital's heparin protocol called for a loading dose of 4,000 units followed by a constant infusion of 900 units/hour. The loading dose was administered correctly, but the nurse inadvertently programmed the continuous dose as 4,000 units/hour. Since the pump limit for heparin as a continuous infusion was set at 2,000 units/hour, the infusion device would not start until the dose was corrected.

In both of the above cases, and in many others discussed in the ISMP Medication Safety Alert!, these mistakes may have gone undetected without preprogrammed limits. For example, we recently received a report where a nurse attempted to program an infusion pump for a baby receiving TPN by inputting 13.0 mL/hour. The decimal point key on the pump was somewhat worn and difficult to engage. Without realizing it, the nurse programmed a rate of 130 mL/hour. Fortunately, the error was discovered within one hour. The baby's glucose rose to 363, so the rate of infusion for the TPN was decreased for a while and the baby was fine. A "smart" pump, programmed with patient and drug parameters, would have been able to recognize the error before the infusion even began.

Clinical trials will be underway soon to quantify the value of these infusion systems in reducing medication error rates. They seem to hold great promise. With CPOE, bar coding and "smart" infusion pumps, we may finally have a solid defense against the most serious medication errors.