| Principal Investigator: | Kermilia Moorer-Whitehead, MSN, RN, NE-BC |
| Organization: | Children’s Health System |
Abstract
Problem
Efforts to ensure patient safety goals require accurate data. Prior to implementation of Alaris smart pumps, it was difficult to track, trend and evaluate medication errors and near miss data. Nurses utilized unsafe methods of IV medication delivery by creating “work arounds”.
Evidence
Data revealed types of programming overrides (12,546 total overrides x6 months) that could cause potential med errors. Smart pump data allows us to evaluate the use of safety mechanisms and outcomes related to areas that could potentially breach safety guardrailed medications. Types of overrides included dose ranges, concentration, and drug dilutions.
Strategy
Interdisciplinary CQI teams were implemented. The top 5 guardrail medications were examined and trended by the CQI data manager. Data trends were disseminated to policy oversight committees to address congruency of safety measures as they related to policy and practices.
Practice Change
As a result of the CQI team evaluation of the data , we have made changes in policies and practices related to the infusion of aminoglycosides; made recommendations to decrease the number of Vancomycin concentrations while introducing standardized dosing; evaluate serious sentinel events where IV pump use was in question. Education of RNs, pharmacy and MDs has been initiated with results pending.
Evaluation
Focus was placed on a six month descriptive data set analysis that revealed specific triggers related to the top 5 guardrailed medications. Monthly analysis of the data showed Vancomycin as the top medication in override status and too many concentrations were available. Data indicated a need for RN medication administration practice and policy changes.
Results
9 total data set changes were implemented during the initial six months. Data set changes were instrumental in decreasing the number of overrides for certain aminoglycosides (example: Clindamycin overrides – Sept 08 = 375 vs. Feb 09= 93).
Recommendations
An interdisciplinary research study was recommended and has been funded to study Vancomycin use and administration practices.
Bibliography
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- Eskew, J.A., Jacobi, J., Buss, W.F., Warhurst, H.M., and DeBord, C.L. Using Innovative Technologies to Set New Safety Standards for the Infusion of Intravenous Medications. Hospital Pharmacy. 2002;37:1179–1189
- Rosenkoetter, M.M., Bowcutt, M., Khasanshina, E.V., Chernecky, C.C., and Wall, J. Perceptions of the Impact of “Smart Pumps” on Nursing and Nursing Care Provided. Journal of the Association for Vascular Access. 2008;13:60–69
- Williams, C.K. Increase the Value of Smart Pump Technology with Sophisticated Data Analysis. Pharmacy Purchasing and Products; June 2007
- Zielski, S. Smart pumps reduce medication delivery errors. Healthcare Purchasing News; December 2007