The Quest to Reduce Infusion Errors

One expert provides tips for how nurses can decrease such errors

  • by Daily Nurse

Infusion errors continue to occur more frequently than they should. In fact, in 2017, the ECRI Institute, an independent nonprofit that strives to improve patient care through researching health care approaches, rated infusion errors as the number one hazard in health technology.

"Infusion pumps are ubiquitous in the hospital. Nine out of 10 patients admitted to the hospital receive an infusion. There are approximately 1.5 million adverse drugs events each year, of which 54% are related to infusion errors," said Sue Niemeier, RN, chief nursing officer at Ivenix. In 2013, she explained that the FDA issued new guidance for infusion pump manufacturers to "improve the quality of infusion pumps in order to reduce the number of recalls and adverse events associated with their use." The most commonly reported infusion pump device problems cited by the FDA are human factors, broken components, battery failure, alarm failure, and over/under infusion. And companies are stepping up to overcome these issues.

"At Ivenix, we have designed an infusion system that helps to put the nurses' focus on their patients, with the guiding principles to simplify every step of the process, remove unnecessary and error-prone tasks, and inform care," said Niemeier. This system, which is awaiting FDA approval, has a pump with an integrated handle with quick release button, eight hours of battery, and bag hooks on the side to facilitate patient mobility. It features a touchscreen to eliminate buttons and possible points of confusion. "The interface was designed with the intent to be as simple and familiar as a smartphone to significantly enhance ease of use and help prevent potential misprogramming of the pump, a common source of user error that can potentially lead to patient harm," Niemeier explained.

"From talking with nurses and observing the challenges that nurses have with current infusion technology, we discovered nurses are forced to know almost as much about the anatomy of their pumps as the anatomy of their patients," said Niemeier. "Valuable nursing time is spent on complex set-up and programming, administration, troubleshooting, manual documentation, and unrelenting alarms that have the potential to increase errors and take clinicians away from the bedside. What we learned from these observation is that in order to help improve infusion delivery, we needed to design an infusion system with the goal of helping nurses put the focus back on their patients, making the clinician's life easier, and, ultimately, patient care safer."

Until this and other new infusion systems are available, Niemeier provided these tips on how nurses can help lessen or put a stop to infusion errors to keep patients safe:

  • When evaluating a new or current infusion pump, there are many key considerations to understand in helping to reduce errors. Ask the following questions:
  • Is the user interface of the pump easily understood by nurses? Are there multiple buttons or other user interface elements that could potentially lead to an error?
  • How easy is the administration set to load/unload in the pump, and is it possible to misload an administration set? A misloaded administration set has the potential to lead to free flow.
  • What are the requirements for the pump to be set up to maintain accurate fluid delivery, and is this impacted by external factors (e.g. medication container height, viscous fluids, or back pressure)?
  • What is the programming workflow for infusions that require multiple programming steps and may therefore be more prone to error? This includes: weight-based infusions; bolus dose infusions; secondary, or intermittent infusions; and multiple infusions given to the same patient.
  • Does the pump have a drug library? If yes, does the interface automatically default to the drug library?
  • What mechanisms are in place to help minimize common sources of alarms, such as air-in-line and occlusions alarms, that may disrupt or distress the patient's environment?
  • How easy is it to assess the status of a patient's infusion without disrupting the patient, particularly during nighttime hours or when managing multiple patients who are on infusions?
  • What mechanisms are in place to allow for ease of transport and/or patient ambulation?
  • How easy is it to change drug libraries as a patient moves through different care areas of the hospital? Is it possible to change a drug library (or care profile) during an active infusion?
  • Does the pump have the capability to communicate with the hospital's EMR to support auto-programming and auto-documentation of infusions to reduce the number of manual steps required by nurses?



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