Thanks to leaps and bounds in infusion system technology, using smart pumps for IV infusion has the potential to be safer than ever. Smart pumps have built-in features to help make sure patients get the proper dosage they need. Some of these safety features include:
- Drug Libraries
- Hard and soft stop alert systems
- Patient ID verification
In spite of these safety features, however, medication errors can still occur when smart pumps are used incorrectly. Specifically, alert systems are sometimes rendered ineffective when hospital staff circumvents them using alert overrides and custom dosages.
Here, we’ll explain why health care workers need to be especially careful when manually entering data into smart pump technology, and how to prevent errors when individualized dose calculation is necessary, such as with pediatric patients.
Avoiding Human Error When Using Infusion Pumps
Smart pumps are specialized hospital equipment designed with safety-net features to reduce error. However, when using a smart pump to administer a drug with a concentration not pre-set in the drug library, the doctor or nurse has to manually enter the drug’s concentration, which creates room for human error. Smart pumps have alert systems to tell the health professional that an inappropriate dosage of a drug has been programmed. However, if the hospital or facility has pre-set the pump with only soft limits for certain drugs, rather than hard limits, the health care worker then has the chance to override the alarm. Sometimes, overriding soft alerts is necessary. Still, when entering custom concentrations and other manual data, health professionals need to be absolutely certain that their data and calculations are correct before overriding alarms.
After conducting a series of surveys, the Institute for Safe Medical Practices found that, when programming custom concentrations, many organizations weren’t setting hard stops for minimum concentrations, so that the only possible alarm that could be tripped by incorrect dosage would be a soft-stop that could be manually overridden. Thinking that the alarm is caused by entering a custom concentration, hospital workers who silence the alarm have inadvertently administered incorrect dosages. Errors like this could potentially lead to a patient receiving a bag of fluid medication over the period of one hour rather than 24, for instance. Even the most common IV fluid, saline, can be dangerous when administered too quickly or in too great a quantity.
These dangers are even greater when misusing smart pumps for custom concentrations in pediatric settings. Often, children need custom concentrations of medicines to account for their lower weight. This means that doctors and nurses are more likely to enter drug information manually when working in pediatric settings, raising the risk of miscalculation. Miscalculation is dangerous for any patient, but medically-complex children in hospital settings are a particular risk. They often cannot communicate symptoms if something doesn’t feel right, and so the chance of a dosage error going unnoticed could be higher.
To avoid errors like these, consider the following:
- Instructing your staff to exercise extreme caution when overriding soft-stop alarms
- Adopting hard stops for custom concentrations whenever possible, especially in pediatric settings
- Adopting specialized medicine labeling, so that a medicine with an individualized concentration is marked with an obvious, colorful label to distinguish it from containers with standard concentrations
