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Critically ill patients often receive potent intravenous drugs with narrow safety margins that require careful titration (monitoring and dose adjustments). So-called "smart" intravenous (IV) infusion systems can detect many drug errors, and they have the potential to reduce the rate of serious medication errors in these patients. However, hospital staff must be educated in their use, according to Jeffrey M. Rothschild, M.D., M.P.H., of Harvard Medical School and Brigham and Women's Hospital.
In a recent study, Dr. Rothschild found that a smart pump system used in the hospital's cardiac surgical intensive care units (ICUs) and step-down monitored units did detect many drug errors. However, there was no difference in the number of serious medication errors that occurred during the periods when the system was used and when it was not.
This may have been because the system made it easy for nurses to bypass the drug library, which specified doses, routes and rates of administration, and other important information. Also, nurses frequently overrode system-generated drug alerts. The system has since been improved to expand the library from 40 to 100 drugs, make the library the default setting (it can't be bypassed), and change the system so the infusion pumps can better handle boluses (single dose of a drug infused over a short time).
In an effort to perform better while providing care to many acutely ill patients, nurses may be taking shortcuts that violate safe IV infusion practice, notes Dr. Rothschild. In his study, which was supported by the Agency for Healthcare Research and Quality (HS11534), pumps were reconfigured to provide point-of-care, real-time decision support feedback for the second and fourth 8-week intervention periods. The feedback feature was inactivated during the first and third 8-week control periods.
For a total of 744 admissions, there were 219 medication errors, including 25 preventable adverse drug events (ADEs) and 155 non-intercepted potential ADEs. The most common types of error were incorrect dosing of titratable drugs and incorrect IV drug rates.
See "Developing the evidence for IV safety—preliminary report from a smart pump study," by Dr. Rothschild, in the December 2004 issue of Healthleaders, pp. 15-20.
Editor's Note: For more information on this topic, see "A controlled trial of smart infusion pumps to improve medication safety in critically ill patients," by Dr. Rothschild, Carol A. Keohane, B.S.N., R.N.,
E. Francis Cook, Sc.D., and others in the March 2005 Critical Care Medicine 33(3), pp. 533-540.
For information on other ICU safety issues, see the following two AHRQ-supported studies. The first study found that adherence to infection control guidelines can greatly minimize catheter-related bloodstream infections in the ICU. For details, see Berenholtz, S.M., Pronovost, P.J., Lipsett, P.A., and others (2004, October). "Eliminating catheter related bloodstream infections in the intensive care unit." (AHRQ grant HS11902). Critical Care Medicine 32(10), pp. 2014-2020. In the second study, researchers describe efforts being made by multiple stakeholders to improve quality and safety in ICUs. For more details, see Pronovost, P.J., and Holzmueller, C.G. (2004, September). "Partnering for quality." (AHRQ grant HS11902). Journal of Critical Care 19(3), pp. 121-129.
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