1. Harrison, Lori Tonya MSN, RNC-OB

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Nurses are in an environment of constant demands to learn new technology to enhance patient care. As the healthcare environment continues to evolve, we find ourselves in an interesting space: working to provide high-quality patient care while leveraging technology. In our rapidly changing setting, the use of evidence-based care and decision support tools are a normal part of our everyday patient care delivery system. In addition, we're seeing the evolution of devices through both consumer demands and functional enhancements or improvements. One such device is the "smart pump."

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Smart pump technology has been recognized to improve medication safety.1 Smart pumps have the ability to provide a safety net to prevent medication errors, as well as capture and record data for later analysis. These pumps offer drug libraries to help guide the clinician through the programming process, trigger user alerts when programming is outside the limits set within the library, and can connect to a network wirelessly to send and receive information. According to, smart pump technology has the potential to avert up to 32% of infusion errors if alerts are triggered and 81% of these errors if the devices are integrated with the medical record.1


The benefits of smart pumps in the clinical setting include:


* drug-based safety limits to help prevent over- or underprogramming


* a safety mechanism to help control free flow


* the ability to monitor programming events to evaluate opportunities for improvement


* verification of near misses that allowed errors to be caught before they reached the patient.2



However, infusion pump error was seen as one of the top 10 technology safety topics in 2014.1 According to, "Ensuring the safe use of health technology requires identifying possible sources of danger and difficulty involving medical devices and systems and taking steps to minimize the likelihood that adverse events will happen."1 To fully maintain smart pump functionality at optimal safety, nurse leaders need to understand the challenges, barriers, and impact on professional practice. Just implementing a smart technology isn't the end of your work as a leader. More likely, it's the beginning of your journey to leverage this technology to improve the quality of patient care. By using a multidisciplinary approach, nurse leaders can affect change and ensure the safe use of these devices.


Boost compliance rates

At Kaiser Permanente, creating a culture of safety is a high priority. After implementing smart pumps with full wireless connectivity, we were able to access the data within these devices and develop a strong plan for continuous improvement. Data can only take you so far in your discovery and understanding of the elements that drive compliance with smart pump safety features. We launched a multidisciplinary improvement project in one of our regions, which we chose because its compliance numbers were in the bottom range compared with other regions, staff members were motivated to change, and its size was ample to capture and test the improvement process.


Our work began by first engaging nursing leadership and analyzing the data to determine the areas of greatest opportunity. We focused on critical care and oncology-the two areas identified as having the greatest potential for improvement-and worked with a multidisciplinary team to quickly establish improvement options. Some of the opportunities for improvement that rose to the top included staff refreshers to ensure a solid understanding of how to use the pump and a more effective process for communication regarding drug library changes.


We then embarked on "gemba" rounding. A Lean methodology similar to the management by walking around approach, gemba is a Japanese term meaning "real place."2 This is the process of observing and interviewing frontline staff members to determine what they recognize as challenges and barriers to using the smart pump safety features. We engaged staff members by observing their workflows and capturing their comments about challenges. Staff members expressed challenges with some of the typical daily workflows, such as titration and bolus infusions. In addition, there was a need for solid communication to inform staff members about additions to the library of new drugs.


After this in-depth analysis, we developed an improvement plan that included staff refresher training, setting clear expectations of practice standards, capturing missing drugs to be added to the smart pump library, and providing visual reminders on the unit about how to program the pump using the safety software. Some of the changes were implemented rapidly. However, some, such as changes to the drug library, required additional time and approvals.


We monitored the results and shared them with staff on a monthly basis. Additional improvements were deployed when available. It was through this concentrated effort and leadership visibility that the two areas were able to improve their compliance rates significantly, achieving a better than 94% compliance rate in the region and a 98% compliance rate in our oncology areas.


There were many factors that contributed to the successful improvement in these areas. Staff members wanted to do the right thing, managers were committed to open communication with staff, and the improvements were made in a concerted and visible fashion to show staff the true commitment of leadership.


Your role

As nurse leaders in a clinical setting where smart tools are leveraged to increase the quality and safety of patient care, we have certain responsibilities to ensure safe implementation, training, and monitoring. It's important to set the expectation for professional behavior and widespread adoption of smart pump technology. If we're clear that the use of smart technology is expected at all times unless a rare scenario occurs, then our staff members know that they must program the pumps using the safety software. At the same time, we need to carefully consider the potential impact of technology on care processes and clinical workflow.


It's vital to remove barriers to successful utilization. Provide thorough training and ensure that the drug library contents meet the needs of your patient population to prevent clinicians from programing the pumps without using the smart technology tool. Frequent checkpoints to identify gaps and a communication process for staff to report missing or inaccurate drugs within the library allow for ongoing changes to be implemented more rapidly. The last component is to monitor the available data to determine your areas of focus and develop a strategic plan for actionable items utilizing a multidisciplinary team.


As with any complex medical device, there are many factors that influence proper use and safe monitoring. Not only do we need to develop and implement tools to prevent harm from reaching a patient, we also need the ability to review data electronically to accurately capture information. With the implementation of smart tools, nurses are being held accountable for the safe use of these devices and are liable if these safety features are bypassed. Nurses have a duty to use reasonable care to ensure that they've engaged the smart pump safety features.3 Therefore, it's critical to make sure that the smart devices utilized in the patient care setting are implemented with a thoughtful approach that provides the necessary training, follow-up monitoring, and other considerations for ongoing improvement opportunities related to this technology.


Focus on patient safety

Patient safety should always be at the center of the design and adoption of any technology introduced into patient care settings. Technology that's designed to improve patient safety is only as good as the person using the device. It doesn't replace critical thinking, solid nursing practice, and careful patient monitoring. As nurse leaders, we need to remain present at the table to ensure that patient safety technology isn't only implemented correctly, but also being utilized in the way it was designed. A systematic approach is needed to determine if the implemented technology is achieving positive results.




1. Top ten health technology hazards for 2014. [Context Link]


2. Johnson PM, Patterson CJ, O Connell MP. Lean methodology: an evidence-based practice approach for healthcare improvement. Nurse Pract. 2013;38(12):1-7. [Context Link]


3. Harding AD, Connolly MW, Wilkerson TO. Nurses' risk without using smart pumps. JONAS Healthc Law Ethics Regul. 2011;13(1):17-20. [Context Link]