1. Dills, Tammy RN, C
  2. Cowan, Debby

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On a typical Tuesday morning, staff nurses were busy with morning care and rounds-taking family and physician calls, preparing patients for tests, and administering AM medications. One patient had a new order for a potassium chloride infusion. The nurse obtained the medication and was programming the infusion pump when she received an alert indicating the rate she had entered for the potassium infusion exceeded dosing limits set by the hospital. Due to the morning's hectic pace and accompanying distractions, the nurse had set the pump to deliver the potassium over 30 minutes, rather than over several hours, as the order stated. The pump's alert prompted her to correct the rate. While neither the nurse nor the patient will ever see the full extent of what could've resulted, both rest a little easier knowing disaster was avoided.


In the United States, as many as 7,000 patients a year die from preventable medication errors.1 This propels many hospitals, such as Angel Medical Center in Franklin, N.C., to take measures to help eliminate these errors. The preceding case involving potassium administration was one of two potential medication errors caught in just 1 week by new safety infusion pumps put into place at the small, 59-bed acute care facility. Imagine how many errors could be thwarted at larger medical institutions during this same time span.


Identifying better measures

Although small, Angel Medical Center is always looking for leading-edge, cost-effective measures to provide patients with the safest and highest quality care. Hospital administrators wanted a system that would make medication delivery safer, allow real-time access to infusion data, and provide data and reports for quality improvement initiatives. The journey to better patient safety began with the adoption of a new infusion pump system with bar-coding technology and dose-tracking infusion management software. This conversion has allowed the hospital to improve medication delivery at all stages of care-from the pharmacist filling the prescriptions to the nurses administering it.


The decision to convert to the new infusion system wasn't taken lightly. For the most part, staff members were happy with their current equipment. But hospital personnel knew there was more they could do to streamline the process for employees and make it safer for patients. It was just a matter of finding the system that would best suit Angel Medical Center's needs.


As the search began, a few things became clear. Angel Medical Center wanted a pump that would allow pharmacists and nurses to work closely together to ensure patients received the correct medications and dosages. Specifically, it had to have dose error reduction software that serves as a safety net for the administration of I.V. medications by alerting the nurse to doses set too high or too low. The pump also had to offer bar coding. Additionally, staff wanted a pump that could provide real-time access to all running pumps, which would allow for better monitoring of infusions.


Enhancing efficiency

Upon implementation of the system with a drug library and bar coding, nurses and pharmacists immediately began to see positive changes. Potential errors were caught before they reached the patient; the alert message requires clinicians to make a "smart stop" and decide whether to proceed and override the alert, or to pause and make a correction.


The bar-coding feature allows pharmacists to include bar codes on all medications. The nurse scans the bar-code label to program the pump, and like manual programming, engages the drug library feature, which serves as a double check that the dose is within hospital limits. The medication is then safely administered to the patient.


An additional advantage of bar coding is the integration with the medication administration record. This saves nursing time spent on documentation and eliminates illegible handwriting and transcription errors. The new infusion system also provides wireless access to real-time infusion data, which allows nurses and pharmacy staff to monitor medication administration remotely from any point in the hospital. This gives pharmacists a tool to monitor infusions and supports improved communication with the treating physician. The reports provide valuable information for ongoing trending of infused medication data and the ability to determine those that were potential errors. By viewing trends over time, educational and process improvement initiatives can be tailored to address areas of concern and provide ongoing monitoring of the effectiveness of those initiatives.


Like any large venture, budget and resources were the two foremost challenges faced when implementing the new patient safety measures. Funds are often allocated towards items that generate revenue, such as MRI or CT systems. While the process of converting to the new infusion pumps is a sizable investment, vendors should be able to work with the facility to customize a package that fits the available budget. Now with the new system and reporting software, staff can monitor and track how many pumps are being used at a given time. This feature assists in locating unused pumps, and, more importantly, helps facility personnel decide if more pumps are needed.


Converting quickly and easily

Along with financing, the timing required to make a conversion can become a challenge. While a conversion won't happen overnight, it shouldn't take months and months. Angel Medical Center's process took only 5 weeks, and the hospital worked with its supplier on customization to meet staff needs. For example, the pharmacy system was tailored to produce a bar-code label with the information required to program the pump.


Support from the supplier is critical to a successful implementation. During the initial conversion, the supplier provided round-the-clock training and consultation for 130 nurses and five pharmacists. In addition, the supplier provided follow-up support to ensure successful technology adoption.


Prognosis for safety

Now that the training is complete and staff members know how to work with the bar-code features and the drug library, the next challenge is to ensure usage consistency regarding the new features. Although pumps may be operated manually, Angel Medical Center will continue training to promote usage of bar coding, the drug library, and the infusion management software.


The outlook for patient safety at Angel Medical Center is positive. By implementing the new systems, the hospital not only is able to improve care delivery, but also enhance communication between nurses and pharmacists. The new system allows staff to help ensure that the right medication, in the right dose, is delivered to the right patient with the right documentation, making medication administration safer. Angel Medical Center strives to be a hospital pushing toward advances in technology to improve patient care. By increasing technological capabilities, these changes support hospitals in delivering the highest quality patient care.




1. IOM Report: To Err is Human. National Academy of Sciences, 2000. [Context Link]