New Medication Pumps Help Prevent Errors

Strong Memorial Invests in Technology to Make Care Safer

April 12, 2004

"This simply provides yet another barrier between the patient and a potential mistake. Even one mistake averted has enormous human and financial benefits."

A recent study published in the Archives of Internal Medicine estimates that as many as one in five doses of medication administered in hospitals is done so erroneously.  The Institute of Medicine’s 1999 report, To Err is Human: Building a Safer Health System, suggests that these medication errors account for at least 7,000 patient deaths annually.

By using computer-driven “smart-pumps,” a handful of hospitals around the country are reducing the chance that their patients will be infused with the incorrect medication or the wrong dose of the right medicine.  Strong Memorial Hospital is one of the first hospitals in New York State to replace all of its intravenous medication pumps with smart-pump technology. 

It’s more than just good medicine.  Aside from the tragic toll in human suffering, medication errors have a significant impact on national health care costs.   Industry experts calculate that America spends between $1.56 and $5.6 billion annually to treat patients who suffer from adverse drug events.  That’s because these patients are hospitalized longer than those treated with the proper medication regimen, and added hospital costs mount to $2,200 to $4,600 per patient.  The problem has sparked a nation-wide drive to prevent medication errors. 

Another Set of Eyes

Kate Miller, RN, BSN, Strong Memorial’s director of Value Analysis, said that Strong made the decision to purchase 739 Medley™ Medication Safety Systems with Guardrails® Safety Software from ALARIS Medical Systems after piloting the technology in two pediatric and five adult intensive care units since September.  “Staff love these pumps because they work like another set of eyes looking over your shoulder,” she said.  “They let you know if something could be wrong before you administer the medication.” 

Each Medley™ System is pre-programmed with dosage, concentration, and rate-of-infusion parameters for each medication, based on hospital protocols that are specific to that particular patient care unit.  If a dose is entered which falls outside of those Guardrails® Limits, the pump will signal an alert on its message screen.  The nurse must then make an active choice to override the pump, or change the dosage or infusion rate to conform to the standards.  “There are instances in which the prescribing physician may, in fact, want a higher- or lower-than-normal dose,” Miller said.  “But this forces us to double-check those exceptions to be absolutely sure.” 

“Medication limits for drugs used in the intensive care units were established by a multidisciplinary team of physicians, nurses and pharmacists,” said Jeff Huntress, Pharm.D., associate director of Pharmacy at Strong Memorial Hospital.  Because the same painstaking approach must now be applied to all of the intravenous medications in Strong’s formulary, the hospital doesn’t expect to have the Medley™ System in place hospital-wide until early April.  Plus, patient care staff must undergo training before using the Smart Pumps. 

“The ALARIS® Medley™ System adds yet another dimension to Strong’s medication safety process that extends from the time the prescription is ordered, through its preparation in the pharmacy, to the moment it is given to the patient,” Huntress said. 

In addition to the guardrail software, the smart pumps also have a locking mechanism found in more traditional pumps that prevents medications from “free-flowing,” which can cause medication levels in patients to surge unintentionally.  The Joint Commission for the Accreditation of Health care Organizations (JCAHO) now requires all medication pumps to be equipped with this safety feature. 

The Medley™ System also prompts users when it is time for maintenance.  In addition, each pump is capable of administering up to four medications simultaneously, and can recognize if attempts are made to infuse duplicate medications. 

A Healthy Investment

Strong Memorial’s multi-million dollar investment is sure to pay off.  In a recent nine-week period, Strong tracked nearly 150,000 medication administrations delivered by the Medley™ System.  About 5% of the time, the pumps signaled an alert.  In the vast majority of these instances, staff chose to override the pump’s alert since the dosage was intentional.  But a small percentage of these alerts signaled “near misses,” instances in which a potential error was avoided. 

Using data downloaded from the Medley™ System’s computers, hospital leaders are now able to track the number of times that the pumps signal alerts and whether or not those alerts were deliberately overridden, information useful in assuring quality.  Plus, data can be studied by a specific drug or by a particular patient care unit.  The computers can also map out what time of day any “near misses” take place so that administrators can spot trends that may relate to staffing patterns or shift changes. 

“In most of these ‘near miss’ instances, staff would have caught the error themselves, but this simply provides yet another barrier between the patient and a potential mistake,” Miller said.  “Even one mistake averted has enormous human and financial benefits.” 

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Teri D'Agostino
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