Enhanced Notification of Infusion Pump Programming Errors

Intermountain Healthcare

•22 hospitals• 12 urban• 10 rural

•2723 licensed beds•Intermountain Medical Center

• 440 licensed beds

The Making of A Smart System

• ICU Safety Team• The problem• The solution

Pump AlertT514

Pump #305

Pump AlertT514

Pump #305

Pump AlertT514

Pump #305

Data Collection

Pt Data

Pump Alerts

Limits were set for high risk medications1. Initial start limits

• Typically set numbers2. Rate change limits

• % changes over last running rates• Set amounts over previous rates• Specific amounts

Pump Alert Limits

Medication Initial Limits Rate Change LimitsFentanyl 250 mcg/hr rate + > 250 mcg/hr increase

Insulin 10 units/hr > 100% inc over last rate

Propofol 50 mcg/kg/min > 80 mcg/kg/min

Heparin 2500 units/hr Rate + > 300 units/hr

Norepinephrine > 0.3 mcg/kg/min If rate 0.01–0.1 then > 200% incIf rate > 0.1 then > 100% inc

Not a comprehensive list

Pump Association

Pump Alert

T501

Pump #305

Pump Alert

T501

Pump #305

Turning Off An Alert

Two methods to inactivate the alert• Fix the error at the pump• Close the screen by clicking the “X”

• Clear this monitor only• Override – enter username

Anatomy of a Pump Alerting E-mail

Pump-Medication Alert Activated 2005-10-05 16:45:01, E918, 101555555, 173, Heparin, 99900.0, 1800.0, 8, 2

2005-10-05 16:45:52, Alert Fixed room: E918; division: UNIT; deviceNumber: 173; med: Heparin; rate: 1950.0; previousRate: 99900.0; orderNumber: 8; bottleNumber: 2

Results

• 22.5 month study• 25 040 administered doses of medications• 970 (4%) alerts generated (1.4 alerts/day)• 137 (14%) alerts prevented potential harm

Results

• Top 5 medications• Fentanyl• Vasopressin• Insulin• Heparin• Propofol

Alert Analysis

• Prevented harm• Improved charting• Provided education• Programming logic changes• Testing the system

Challenges

• Setting limits• Alert fatigue• Big brother is watching• Education

Advantages

• Few steps involved• Any pump will work• Database is kept in central location• Tied to electronic medical record• Simple to complex alerts

Acknowledgements

Rick Carlson, PharmD, BCPSTerry P. Clemmer, MDR. Scott Evans, MS, PhD, FACMISteve Howe, BS, MSKyle V. Johnson, BSJames F. Lloyd, BSJames F. Orme, MDBrent K. Palmer, BSN

Thank You