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Advancing Medication Infusion Safety Through the Clinical Integration of Technology a
b
Donald Gerhart Jr RPh , Kristen O'Shea MS, RN, NEA-BC & Sharon Muller MSN, RN a
Medication Safety Officer and Pharmacy Quality Assessment Manager
b
Clinical Transformation Officer
c
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Director, Clinical Informatics; WellSpan Health, York, PA Published online: 28 May 2015.
To cite this article: Donald Gerhart Jr RPh, Kristen O'Shea MS, RN, NEA-BC & Sharon Muller MSN, RN (2013) Advancing Medication Infusion Safety Through the Clinical Integration of Technology, Hospital Practice, 41:4, 7-14 To link to this article: http://dx.doi.org/10.3810/hp.2013.10.1075
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C l i n i c a l F o c u s : C o n s e n s u s G u i d e l i n e s a n d P a t h w ay s P r e - a n d P o s t- A d m i s s i o n
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Advancing Medication Infusion Safety Through the Clinical Integration of Technology
Donald Gerhart Jr, RPh 1 Kristen O’Shea, MS, RN, NEA-BC 2 Sharon Muller, MSN, RN 3 1 Medication Safety Officer and Pharmacy Quality Assessment Manager; 2Clinical Transformation Officer; 3Director, Clinical Informatics; WellSpan Health, York, PA
DOI: 10.3810/hp.2013.10.1075
Abstract: Adverse drug events resulting from errors in prescribing or administering medications are preventable. Within a hospital system, numerous technologies are employed to address the common sources of medication error, including the use of electronic medical records, physician order entry, smart infusion pumps, and barcode medication administration systems. Infusion safety is inherently risky because of the high-risk medications administered and the lack of integration among the stand-alone systems in most institutions. Intravenous clinical integration (IVCI) is a technology that connects electronic medical records, physician order entry, smart infusion pumps, and barcode medication administration systems. It combines the safety features of an automatically programmed infusion pump (drug, concentration, infusion rate, and patient weight, all auto-programmed into the device) with software that provides visibility to real-time clinical infusion data. Our article describes the characteristics of IVCI at WellSpan Health and its impact on patient safety. The integrated infusion system has the capability of reducing medication errors, improving patient care, reducing in-facility costs, and supporting asset management. It can enhance continuous quality improvement efforts and efficiency of clinical work flow. After implementing IVCI, the institution realized a safer patient environment and a more streamlined work flow for pharmacy and nursing. Keywords: interoperability; device integration; infusion safety; intravenous medication safety; medication errors
Introduction
Correspondence: Donald Gerhart Jr, RPh, Department of Pharmacy, York Hospital, 1001 South George St, York, PA 17403. Tel: 717-851-2987 Fax: 717-851-2089 E-mail: [email protected]
In 2006, the Institute of Medicine reported that medication errors occur at the rate of 1 per patient per day in US hospitals at a total cost per error of approximately $8,750.1 In response to this alarming report, accreditation bodies, payers, and hospitals launched major initiatives and invested considerable resources to improve patient safety.2–11 The Joint Commission requires each hospital to designate an individual to carry the safety responsibilities.6 This individual generally is responsible for creating productive team interactions, ensuring reliably designed processes, and promoting the value of a just culture. Although advances have been made in procedural methods to decrease errors, mistakes continue to occur.10,11 In a recent study in 10 hospitals,2 investigators found that harm to patients remains common, with little evidence of widespread improvement despite many attempts to create safer environments.2 Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time.
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Rationale
High-risk medications are usually administered by intravenous (IV) infusion in the intensive care unit (ICU). As the population ages, the number of ICU patients dramatically increases. With a greater reliance on technology to keep critically ill patients alive, the number of ICU beds has grown dramatically in the United States, with the current estimate being . 6000. Between 2000 and 2005, annual critical care medicine costs increased from $56.6 to $81.7 billion, representing 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of gross domestic product. More than 5 million patients are admitted annually to US ICUs. Also evident is the dramatic increase in patients aged $ 85 years—from 4.1% in 1991, to 6.9% in 2004. Between 2000 and 2020, the population of those aged . 65 years is expected to grow by approximately 10%, whereas the number of individuals who are aged $ 65 years is projected to rise by approximately 50%.12 From these statistics, it is obvious that in the future, the typical patient will be at greater risk of a serious medication error due to a high-risk medication. The Institute of Medicine recommends the effective use of well-designed technologies to deliver safe drug care.1 The report states: “The use of technology will undoubtedly lead to major improvements in all settings. Administration is a particularly vulnerable stage in the medication-use process, and several technologies are likely to be especially important in this stage. These include electronic medication administration records, as well as machine-readable identification, such as bar coding, and smart (intelligent) IV infusion pumps. All these technologies should be linked electronically.”1
Through this directive by the Institute of Medicine, institutions are aiming for the integration of health care information technology and care delivery devices into an aggregate process that includes electronic streaming of clinical documentation. A number of technologies have been employed by organizations to reduce the risk of medication errors, including electronic health record (EHR), computerized provider order entry (CPOE), pharmacy automation and information systems, barcode medication administration systems, and smart infusion devices. Each of the systems presents the opportunity to address sources of infusion errors.13–15 As separate technologies, each is limited in assuring patient safety; however, as a fully integrated system, they have the potential for significant benefits.16,17 The purpose of our article is to describe how our health care system implemented an intravenous clinical integration (IVCI) infusion management system that leverages the physician 8
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order (established through CPOE), smart pump technology, bar code verification (autoprogramming), and linkage of the smart pump to the electronic record.16–22 WellSpan Health System is a community-based, not-forprofit health delivery organization that operates 10 outpatient health centers and 3 hospitals (York, Gettysburg, and WellSpan Surgery and Rehabilitation), serving . 450 000 patients across south-central Pennsylvania and northern Maryland. WellSpan conducts “Daily Safety Brief” meetings. Members attending these daily briefs include the medication safety officer, office of the president, vice presidents of medical affairs, nursing, patient, and employee safety, as well as clinical departmental directors. The meetings have proven to be an excellent method of communicating errors across the institution, identifying and analyzing root causes, and implementing proactive solutions in a timely manner to ensure a safer patient environment.
Description of Intravenous Clinical Integration
Intravenous clinical integration is a technology that combines the safety features of an automatically programmed infusion pump (drug, concentration, infusion rate, and patient weight, all auto-programmed into the device) with software that provides visibility with real-time clinical infusion data. An integrated infusion management system offers clinicians the ability to associate a device and a medication or continuous infusion order with the patient’s EHR and have wireless 2-way communication, streaming infusion volumes and titrations automatically from the IV pump to the EHR and from the EHR to the IV pump. In this manner, multiple devices can send data to a single location: the EHR. WellSpan is one of the first organizations to successfully integrate multiple clinical medication-use technologies into a full-functioning infusion management system. Prior to the implementation of IVCI at WellSpan Health, the processes surrounding the implementation and maintenance of infusion devices were each conducted within the silos that existed in Biomedical Engineering, Pharmacy, and Nursing, respectively. The initial implementation of smart infusion pumps began breaking down walls due to both the sophistication of the technology itself and the universal goal of everyone involved to provide safer infusion administration to all patients. In partnership with its IV pump vendor and enterprise clinical information system supplier, Wellspan’s York Hospital integrated infusion management and smart pump autoprogramming software with smart infusion devices,
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supported by drug library safety software with WellSpan’s existing EHR and pharmacy information systems. In this fully integrated infusion management system at WellSpan, a prescriber electronically enters an IV medication order, which is verified by a pharmacist and becomes part of the patient’s EHR via the electronic medication administration record (eMAR). Once a medication is ordered via CPOE, the nurse accesses the patient’s eMAR via a bedside or mobile computing device and scans the patient’s barcoded wristband as one of the methods to establish positive patient identification. Next, the nurse scans the barcode on the IV medication bag and verifies that the medication matches the provider’s order displayed in the eMAR. The nurse then scans the bar code attached to the smart-pump infusion-device channel, which associates the patient and medication order with the infusion device and automatically sends the infusion parameters, including medication, dose, rate, volume to be infused, and certain other patient parameters (eg, patient weight) to the pump. The nurse uses critical thinking and employs clinical judgment prior to accepting the autoprogrammed settings and adjusts the settings when initiating a titratable dose. Once communication starts, a number of views, referred to as gadgets, are available to the health care team. The device-association gadget displays all of the devices that are associated with a given patient, that is, IV pumps/medications, ventilators, and monitors. The infusion-status gadget
displays all of the patient’s associated infusions and their status, including the amount infused and the total volume to be infused. It makes use of color coding in red, yellow, or green to show the volume remaining. This tool enhances patient safety because a low infusion volume can be easily noticed, which, in turn, decreases the likelihood of an IV medication running out before replacement is available. The color yellow indicates that there is , 1 hour of medication remaining; red signals that there is , 30 minutes of medication left in the IV. The infusion-documentation gadget is used primarily to view and document infusion data. In this view, real-time infusion and hemodynamic data populating the EHR, including infusion rate, dose, titrations, and hourly volume infused, are shown. Previously, these data needed to be entered manually into the EHR. Additional benefits of this gadget include a real-time context for changes to the infusion, titration by titration, as an additional set of hemodynamics and vital signs are included with every titration. A safety mechanism prompts the nurse to view all of the unverified data prior to signing, adding an additional layer of safety for the patient. The infusion-graphing gadget provides a real-time graphic depiction of infusion and hemodynamic data directly from the devices (Figure 1). Displayed data include patient vital signs, hemodynamics, infusion rates, and titrations, as well as the last 12 hours of signed data and 4 hours of streaming (unsigned) data.
Figure 1. Infusion graphing gadget.
Abbreviations: bpm, beats per minute; CVP, central venous pressure; DBP, diastolic blood pressure; EDT, eastern daylight time; HR, heart rate; MAP, mean arterial pressure; O2, oxygen; RR, respiratory rate; SBP, systolic blood pressure; T(axil), temperature (axillary); T(rect), temperature (rectal); UOP, urine output.
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For the pharmacy department, IVCI provides an opportunity for insight into the real-time infusion status of all continuous infusions associated with a smart infusion device across all patient care areas. Use of IVCI eliminates the need for unit-based monitoring of each individual infusion by the bedside nurse, the need for intervention by a pharmacist at the front end of the reorder process, and the distractions caused by the previous lack of transparency of the infusion production process. The end result of this integration is a transparent IV infusion administration and production process that results in improved patient safety and is mutually beneficial to nursing and pharmacy personnel alike. The pharmacy dashboard is largely a non-interactive view that displays all of the infusions currently associated with infusion pumps throughout the hospital. It is automatically sorted in order of time remaining per infusion, which enables pharmacy personnel to quickly ascertain those infusions that are top priority. The use of this work flow-management software in conjunction with the dashboard views allow for a streamlined and standardized IV infusion production process that provides insight on where each infusion is in its production cycle. The process largely decreases the interruptions to staff and the potential resulting errors, thereby promoting a safer patient environment. A tool that is useful to both nursing and pharmacy is the unit-view gadget. This is a multi-patient perspective that can be used at a central nursing station to track infusions, as well as dosages, rates, and the remaining volume for each. The unit view allows both nursing and pharmacy staff to easily see what infusions will be needed within 2 hours or less. The hovering feature provides the same level of detail, including
the status of infusions in the pharmacy process (Figure 2), thereby eliminating many needless phone calls from nursing to pharmacy to find out where patient medication is in the dispensing process, which had previously caused disruption to both nursing and pharmacy. The work-flow management software also indicates when the infusion leaves the pharmacy and changes the status to delivered.
Results
From January 15, 2012 to June 30, 2012, the drug library (ie, safety software) compliance rate was measured to be 97%. Use of the safety software is extremely important because of the great potential for harm associated with high-risk medications identified in the drug library. During the same time period, compliance with IVCI autoprogramming was determined to be 81%. The reasons for missed opportunities for autoprogramming were determined to be related to specific infusions (ie, blood products, IV flush bags, and medications that must be titrated), as well as any infusions administered during information technology downtime that require manual programming. Analysis of the software data and reports identified prevention of 782 significant near-miss medication errors during this time frame. Example of near-miss medication errors that violated the upper hard limits are provided in Table 1. These near-missed errors are reported and discussed during the Daily Safety Briefs to increase staff awareness and potentially prevent reoccurrence in the future. Table 2 presents a comparison of the number of edits made when administering infusions using the IVCI system compared with not using the IVCI system (non-IVCI). Use of the IVCI is associated with an increased rate of a ccuracy
Figure 2. Unit view gadget.
Reprinted with permission O’Shea KL. Infusion management: Working smarter, not harder. Hosp Pharm. 2013;48(suppl 3):S1–S4. www.hospital-pharmacy.com.27
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Table 1. Examples of Near-Miss Medication Errors Medication/Concentration
Upper Hard Limit
Initial Dose
Final Dose
Variance (%)
EPINEPHrine 16 mg/250 mL Vecuronium 50 mg/250 mL NOREPINEPHrine 4 mg/250 mL Midazolam 100 mg/100 mL Phenylephrine 250 mg/250 mL Amiodarone 360 mg/200 mL Midazolam 250 mg/250 mL Nitroprusside 50 mg/250 mL Iron sucrose 500 mg/275 mL Vasopressin 40 units/100 mL DOPamine 400 mg/250 mL Insulin regular 250 units/250 mL
0.5 mcg/kg/min 1.67 mcg/kg/min 1 mcg/kg/min 50 mg/h 9 mcg/kg/min 33.4 mL/h 50 mg/h 10 mcg/kg/min 69 mL/h 0.9 units/min 20 mcg/kg/min 50 units/h
110 mcg/kg/min 200 mcg/kg/min 90.6 mcg/kg/min 999 mg/h 164 mcg/kg/min 500 mL/h 500 mg/h 82 mcg/kg/min 500 mL/h 6 units/min 133 mcg/kg/min 300 units/h
0.05 mcg/kg/min 1 mcg/kg/min 0.04 mcg/kg/min 15 mg/h 5 mcg/kg/min 33.4 mL/h 50 mg/h 0.5 mcg/kg/min 60 mL/h 0.04 units/min 5 mcg/kg/min 2 units/h
10000.00 10000.00 8960.00 1898.00 1722.22 1397.01 900.00 720.00 624.64 566.67 565.00 500.00
when entering the information correctly the first time because there is no manual programming of the device. For levofloxacin, twice as many edits were made when the infusions were manually programmed (non-IVCI) compared with when the infusions were autoprogrammed (IVCI; 8.43% vs 4.2%, respectively). For vancomycin, 3 times as many edits were made when the infusions were manually programmed (non-IVCI) compared with using the IVCI method (6.85% vs 2.17%, respectively). For all other high-risk medication infusions, twice as many edits were made when the infusions were initiated by using non-IVCI compared with using IVCI (2.78% vs 1.39%). Another noteworthy advantage associated with use of IVCI compared with non-IVCI use is the number of edits made at the final confirmation screen. The confirmed and changed on final screen columns in Table 2 reflect the fact that the infusion program was changed at the last possible point of entry to the patient. The clinician approved an errant entry initially, ignoring the alert, and caught the error on the final screen prior to initiating the infusion. This sequence of events occurs more frequently for the non-IVCI infusions compared with the IVCI infusions, again resulting in more
accurate infusion programming with IVCI. Specifically for non-IVCI, 9.95% of high-risk infusions were edited at the confirmation screen compared with 2.57% with IVCI. Table 3 depicts the cost avoidance for a 1-year period associated with use of safety software and IVCI. There are significantly more edits and cost avoidance with non-IVCI than IVCI; the reason for this difference is because the use of IVCI is associated with higher programming accuracy, therefore errant rates are not entered at the outset. Analysis of the software data and reports identified prevention of 1307 near-miss medication errors during a 12-month period for the non-IVCI units and 400 significant near-miss events in the IVCI units, all of which could have caused severe—if not fatal—events had they not been intercepted by the safety software (Table 3). Assuming an estimated cost of $8,750 for each medication error,1 this finding translates into an estimated cost avoidance of $3,500,000 per year for the 3 units that used IVCI and $11,436,250 per year for the non-IVCI units. The latter numbers reflect the importance of the safety software in preventing errors associated with high-risk medication infusions that cannot be autoprogrammed using IVCI. Realistically, not all of the
Table 2. Summary of Edits and Actions Taken: IVCI vs Non-IVCI Medication
Total Programs
Sum HL Edits
Sum SL Edits
Total Edits
Total Overrides
Infusion Confirmed
Changed on Final Screena
Levofloxacin Non-IVCI CCAs (%) IVCI CCAs (%) Vancomycin NON-IVCI CCAs (%) IVCI CCAs (%) Other High-Risk Medications NON-IVCI CCAs (%) IVCI CCAs (%)
5611
452 8.43 4.20 567 5.92 1.81 447
0
0
5010
90 0.93 0.36 303
452 8.43 4.20 657 6.85 2.17 750
76 0.70 0.99 343
7973
601 11.35 4.46 2374 24.16 12.83 2885
1.65 0.76
1.12 0.62
2.78 1.39
1.27 0.86
10347
26978
24313
9.95 2.57
a Infusion was edited at the confirmation screen. Abbreviations: CCAs, clinical care area; HL, hard limit; SL, soft limit; IVCI, intravenous clinical integration.
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Table 3. Annualized Total Significant Critical Catch Edits: IVCI vs Non-IVCI Limits
Soft Limits Hard Limits Total
IVCI (n = 37 241)
Non-IVCI (n = 176 027)
Critical Catchesa
Significant Edits,b n (%)
Cost Avoidance,c $
Critical Catchesa
Significant Edits,b n (%)
Cost Avoidance,c $
270 378 648
107 (39.5) 293 (77.5) 400 (61.7)
936,250 2,563,750 3,500,000
775 1512 2287
487 (62.8) 820 (54.2) 1307 (57.2)
4,261,250 7,175,000 11,436,250
Violating an institutional-defined limit. Edit prevented significant patient harm. c $8,750 per ADR.1 Abbreviations: ADR, adverse drug reaction; IVCI, intravenous clinical integration. a
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b
errors prevented by the pump’s safety software and the use of IVCI with autoprogramming would have caused harm to the patient. A published study23 suggests that 7% of the total number of reported critical catches would have actually resulted in errors that had a negative clinical impact on patients. Methodologies used in the study to deliberately remove programming edits that were not as likely to cause harm translate into a potentially larger percentage of these edits that would have negatively impacted patients. However, a conservative approach to use the 7% cost avoidance was adopted in the absence of conclusive evidence of what impact the study’s methodologies may have had on results. Patient safety was enhanced through increasing efficiency and decreasing interruptions for both Nursing and Pharmacy. Overall, there was a 27% reduction in nursing time achieved with the use of the integrated system when starting and documenting each new infusion. Numerous steps in the process of manually programming the pumps are eliminated with the IVCI process. The number of clicks or manual programming steps on the infusion pump was reduced from an average of 27 (as high as 42) to 7 when autoprogramming a weight-based medication. Also, a time-and-motion analysis was initially done in one IVCI unit that revealed a 50% reduction in nursing time was required to titrate an existing infusion and document the action. This resulted in a nursing labor time reduction of 13 to 16 seconds per titration, which equates to 1300 nursing hours per year saved for that one unit. WellSpan is now using the IVCI process in 3 units, which should result in significantly more nursing time saved. This time savings directly results in the nurses’ focus being transferred from the task of data entry to the work of patient-centered care, and ultimately translates into a safer patient environment.
Discussion
Until recently, health care did not have the tools necessary to prospectively analyze or concurrently compare causal mechanisms for different types of adverse events.24 This 12
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situation is changing as health care begins to adopt safety methods using real-time objective data. Previously, WellSpan applied a failure modes and effects analysis (FMEA) as a method to reduce the risk of future errors; however, this technique used subjective data. WellSpan now employs a more advanced technique that models multiple combinations of events leading to a single outcome, sociotechnical probabilistic risk assessment. Sociotechnical probabilistic risk assessment can be used to identify common systemic and behavioral elements that increase or reduce the risk of serious errors. The integration of IV infusion pumps equipped with safety software with institutional information systems (eg, EHRs, bar code point-of-care, CPOE), provides real-time objective data that can be assessed using sociotechnical probabilistic risk assessment. Through IVCI, medication errors are reduced and nursing work flow simplified and improved.17 The collection of data that flows to the EHR is accurate and timely. Real-time data are available for all users of the EHR. In addition, patient care could be directed toward evidence-based standards, thereby increasing patient safety.25 Among the specific benefits of systems integration is that it relieves nursing personnel from the responsibilities surrounding reorder notification (Table 4). Fewer interruptions in work flow, for both pharmacists and nurses, helps to minimize risk of errors. Pharmacy-based monitoring decreases potential interruptions in therapy related to lack of products and, therefore, clinical risk to the patient. Research has shown that the risk of a harmful medication error is doubled when health care professionals are interrupted 4 times during a single drug administration and tripled when interrupted 6 times.26 By streamlining IV administration through technology integration, major medication errors may be diverted. There is also decreased potential for wrong drug and/or patient errors due to a stockpile of infusions in the patient care area. Additionally, use of IVCI has safeguards
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Table 4. Patient Safety Benefits of IVCI • Right patient, right drug, right route • Right device and channel – Data accuracy – Real-time data available for caregivers – Efficient: High-acuity multi-titrations • Decreased interruptions for pharmacists and nurses helps to minimize risk of errors – Decreased interruptions = Increased efficiency – Time regained can be refocused to more important clinical care activities • Pharmacy-based monitoring decreases potential interruptions in therapy related to lack of product • Decreases risk of administering discontinued medications • Decreases potential for wrong drug/patient errors associated with stockpile of infusions in patient care area • Decreases likelihood for administration of product that has outlived its stability is minimized Abbreviation: IVCI, intravenous clinical integration.
that ensure drugs do not have expired stability when they are being infused. Decreases in time spent communicating and decreased interruptions in pharmacy work flow translate into increased efficiency within the order verification and entry processes. The time regained can be refocused on more important clinical care activities. As with any new technology, several challenges were faced that were associated with the implementation of IVCI technology. Initially, it was a challenge to get the interfaces to communicate properly and the importance of having information technology involved was realized. Other challenges included times when the system must be down, thus reverting to a manual state, persuading clinicians to adopt the new technology. As more institutions integrate technology, controlled randomized trials and statistical analyses should be conducted to more accurately ascertain the impact of IVCI. An example of IVCI positively impacting patient care and nursing work flow can be seen in an emergent situation such as a code.8 Before IV integration, the nurse relied on memory and limited notes, often jotted down on paper towels or scraps of paper, to retrospectively document the infusions administered during a code. This manual process often took as much as 2 hours to complete for a single code. With IVCI, infusion data, titrations, and time stamps are captured on the pump throughout the code. The system streams information directly from the infusion pump during the code and associates all the information with patient physiologic and hemodynamic parameters from cardiac monitors. The nurse reviews the data, revises if necessary, and signs the electronic record. The synchronized data are accurately recorded automatically
in the infusion management system, thus reducing postcode documentation time to just 5 minutes.16
Conclusion
Through integration of stand-alone technologies, WellSpan has found IVCI to be a viable way to enhance not only patient safety but also staff efficiency. An integrated infusion system can help reduce medication errors, improve patient care, reduce in-facility costs, and support asset management. It can enhance continuous quality improvement efforts and help improve clinical work flow.
Acknowledgments
The authors wish to acknowledge Anne Gentry, PharmD, for her assistance with manuscript preparation and Devy Lee, BSc (Pharm), CMPP, for her assistance with data retrieval.
Conflict of Interest Statement
Donald Gerhart Jr, RPh, discloses that he serves as a consultant for Hospira, Inc and Cerner Corporation. Kristen O’Shea, MS, RN, NEA-BC, and Sharon Muller, MSN, RN, report no conflicts of interest. References
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Gerhart et al 11. Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. http://www.iom.edu/∼/media/Files/Report%20 Files/2011/Health-IT/HIT%20and%20 Patient%20Safety.pdf. Accessed September 12, 2013. 12. Society of Critical Care Medicine. Critical Care Statistics. Mount Prospect, IL: SCCM; 2012. http://www.sccm.org/Communications/Pages/ CriticalCareStats.aspx. Accessed August 21, 2013. 13. Raman K, Heelon M, Kerr G, Higgins TL. Addressing challenges in bar-code scanning of large-volume infusion bags. Am J Health Syst Pharm. 2011;68(15):1450–1453. 14. Carayon P, Hundt AS, Wetterneck TB. Nurses’ acceptance of Smart IV pump technology. Int J Med Inform. 2010;79(6):401–411. 15. ECRI Institute releases top 10 health technology hazards for 2013. TechNation (The Bench). 2013;42:28–30. https://www.ecri.org/Documents/ Reprints/ECRI_Institute_Releases_Top_10_Health_Technology_ Hazards_for_2013(TechNation).pdf. Accessed August 21, 2013. 16. O’Shea K, Gerhart D Jr, McKniff S, Muller S, Kline J. Practical considerations for ensuring a safe patient environment with integrated techno logy. Boston, MA: National Patient Safety Foundation; 2012:1–6. 17. Prusch AE, Suess TM, Paoletti RD, Olin ST, Watts SD. Integrating technology to improve medication administration. Am J Health Syst Pharm. 2011;68(9):835–842. 18. Robkin M. A short history of interoperability. Published in 2010. www. mdpnp.org/uploads/1_Robkin_26 Jan.pdf. Accessed August 19, 2013. 19. O’Shea K. Infusion management: one journey in clinical innovation. Biomed Instrum Technol. 2012;46(1):25–28. 20. Association for the Advancement of Medical Instrumentation. Medical Device Interoperability. AAMI White Paper. www.aami.org/interoperability/Materials/MDI_1203.pdf. Arlington, VA: AAMI; 2012. Accessed August 19, 2013.
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21. Association for the Advancement of Medical Instrumentation. AAMI, UL Team Up on Interoperability Standards. AAMI News. October 2012. http://www.aami.org/publications/AAMINews/Oct2012/AAMI_UL_ Team_Up_Interoperability_Standards.html. Accessed August 19, 2013. 22. Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent medication errors in a community hospital network. Am J Health Syst Pharm. 2005;62(24):2619–2625. 23. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897–1903. 24. Comden SC, Marx D, Murphy-Carley M, Hale M. Using probabilistic risk assessment to model medication system failures in long-term care facilities. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation. Volume 2: Concepts and Methodology. (AHRQ Publication No. 05–0021–2. Section: Cognition, Systems, and Risk). Rockville, MD: Agency for Healthcare Research and Quality; 2005:395–408. 25. Schilling MB, Sandoval S. Impact of intelligent intravenous infusion pumps on directing care toward evidence-based standards: a retrospective data analysis. Hosp Pract (Minneap). 2011;39(3):113–121. 26. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–690. 27. O’Shea KL. Infusion management: Working smarter, not harder. Hosp Pharm. 2013;48(suppl 3):S1–S4.
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Advancing Medication Infusion Safety Through the Clinical Integration of Technology a
b
Donald Gerhart Jr RPh , Kristen O'Shea MS, RN, NEA-BC & Sharon Muller MSN, RN a
Medication Safety Officer and Pharmacy Quality Assessment Manager
b
Clinical Transformation Officer
c
c
Director, Clinical Informatics; WellSpan Health, York, PA Published online: 28 May 2015.
To cite this article: Donald Gerhart Jr RPh, Kristen O'Shea MS, RN, NEA-BC & Sharon Muller MSN, RN (2013) Advancing Medication Infusion Safety Through the Clinical Integration of Technology, Hospital Practice, 41:4, 7-14 To link to this article: http://dx.doi.org/10.3810/hp.2013.10.1075
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Advancing Medication Infusion Safety Through the Clinical Integration of Technology
Donald Gerhart Jr, RPh 1 Kristen O’Shea, MS, RN, NEA-BC 2 Sharon Muller, MSN, RN 3 1 Medication Safety Officer and Pharmacy Quality Assessment Manager; 2Clinical Transformation Officer; 3Director, Clinical Informatics; WellSpan Health, York, PA
DOI: 10.3810/hp.2013.10.1075
Abstract: Adverse drug events resulting from errors in prescribing or administering medications are preventable. Within a hospital system, numerous technologies are employed to address the common sources of medication error, including the use of electronic medical records, physician order entry, smart infusion pumps, and barcode medication administration systems. Infusion safety is inherently risky because of the high-risk medications administered and the lack of integration among the stand-alone systems in most institutions. Intravenous clinical integration (IVCI) is a technology that connects electronic medical records, physician order entry, smart infusion pumps, and barcode medication administration systems. It combines the safety features of an automatically programmed infusion pump (drug, concentration, infusion rate, and patient weight, all auto-programmed into the device) with software that provides visibility to real-time clinical infusion data. Our article describes the characteristics of IVCI at WellSpan Health and its impact on patient safety. The integrated infusion system has the capability of reducing medication errors, improving patient care, reducing in-facility costs, and supporting asset management. It can enhance continuous quality improvement efforts and efficiency of clinical work flow. After implementing IVCI, the institution realized a safer patient environment and a more streamlined work flow for pharmacy and nursing. Keywords: interoperability; device integration; infusion safety; intravenous medication safety; medication errors
Introduction
Correspondence: Donald Gerhart Jr, RPh, Department of Pharmacy, York Hospital, 1001 South George St, York, PA 17403. Tel: 717-851-2987 Fax: 717-851-2089 E-mail: [email protected]
In 2006, the Institute of Medicine reported that medication errors occur at the rate of 1 per patient per day in US hospitals at a total cost per error of approximately $8,750.1 In response to this alarming report, accreditation bodies, payers, and hospitals launched major initiatives and invested considerable resources to improve patient safety.2–11 The Joint Commission requires each hospital to designate an individual to carry the safety responsibilities.6 This individual generally is responsible for creating productive team interactions, ensuring reliably designed processes, and promoting the value of a just culture. Although advances have been made in procedural methods to decrease errors, mistakes continue to occur.10,11 In a recent study in 10 hospitals,2 investigators found that harm to patients remains common, with little evidence of widespread improvement despite many attempts to create safer environments.2 Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time.
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Rationale
High-risk medications are usually administered by intravenous (IV) infusion in the intensive care unit (ICU). As the population ages, the number of ICU patients dramatically increases. With a greater reliance on technology to keep critically ill patients alive, the number of ICU beds has grown dramatically in the United States, with the current estimate being . 6000. Between 2000 and 2005, annual critical care medicine costs increased from $56.6 to $81.7 billion, representing 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of gross domestic product. More than 5 million patients are admitted annually to US ICUs. Also evident is the dramatic increase in patients aged $ 85 years—from 4.1% in 1991, to 6.9% in 2004. Between 2000 and 2020, the population of those aged . 65 years is expected to grow by approximately 10%, whereas the number of individuals who are aged $ 65 years is projected to rise by approximately 50%.12 From these statistics, it is obvious that in the future, the typical patient will be at greater risk of a serious medication error due to a high-risk medication. The Institute of Medicine recommends the effective use of well-designed technologies to deliver safe drug care.1 The report states: “The use of technology will undoubtedly lead to major improvements in all settings. Administration is a particularly vulnerable stage in the medication-use process, and several technologies are likely to be especially important in this stage. These include electronic medication administration records, as well as machine-readable identification, such as bar coding, and smart (intelligent) IV infusion pumps. All these technologies should be linked electronically.”1
Through this directive by the Institute of Medicine, institutions are aiming for the integration of health care information technology and care delivery devices into an aggregate process that includes electronic streaming of clinical documentation. A number of technologies have been employed by organizations to reduce the risk of medication errors, including electronic health record (EHR), computerized provider order entry (CPOE), pharmacy automation and information systems, barcode medication administration systems, and smart infusion devices. Each of the systems presents the opportunity to address sources of infusion errors.13–15 As separate technologies, each is limited in assuring patient safety; however, as a fully integrated system, they have the potential for significant benefits.16,17 The purpose of our article is to describe how our health care system implemented an intravenous clinical integration (IVCI) infusion management system that leverages the physician 8
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order (established through CPOE), smart pump technology, bar code verification (autoprogramming), and linkage of the smart pump to the electronic record.16–22 WellSpan Health System is a community-based, not-forprofit health delivery organization that operates 10 outpatient health centers and 3 hospitals (York, Gettysburg, and WellSpan Surgery and Rehabilitation), serving . 450 000 patients across south-central Pennsylvania and northern Maryland. WellSpan conducts “Daily Safety Brief” meetings. Members attending these daily briefs include the medication safety officer, office of the president, vice presidents of medical affairs, nursing, patient, and employee safety, as well as clinical departmental directors. The meetings have proven to be an excellent method of communicating errors across the institution, identifying and analyzing root causes, and implementing proactive solutions in a timely manner to ensure a safer patient environment.
Description of Intravenous Clinical Integration
Intravenous clinical integration is a technology that combines the safety features of an automatically programmed infusion pump (drug, concentration, infusion rate, and patient weight, all auto-programmed into the device) with software that provides visibility with real-time clinical infusion data. An integrated infusion management system offers clinicians the ability to associate a device and a medication or continuous infusion order with the patient’s EHR and have wireless 2-way communication, streaming infusion volumes and titrations automatically from the IV pump to the EHR and from the EHR to the IV pump. In this manner, multiple devices can send data to a single location: the EHR. WellSpan is one of the first organizations to successfully integrate multiple clinical medication-use technologies into a full-functioning infusion management system. Prior to the implementation of IVCI at WellSpan Health, the processes surrounding the implementation and maintenance of infusion devices were each conducted within the silos that existed in Biomedical Engineering, Pharmacy, and Nursing, respectively. The initial implementation of smart infusion pumps began breaking down walls due to both the sophistication of the technology itself and the universal goal of everyone involved to provide safer infusion administration to all patients. In partnership with its IV pump vendor and enterprise clinical information system supplier, Wellspan’s York Hospital integrated infusion management and smart pump autoprogramming software with smart infusion devices,
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supported by drug library safety software with WellSpan’s existing EHR and pharmacy information systems. In this fully integrated infusion management system at WellSpan, a prescriber electronically enters an IV medication order, which is verified by a pharmacist and becomes part of the patient’s EHR via the electronic medication administration record (eMAR). Once a medication is ordered via CPOE, the nurse accesses the patient’s eMAR via a bedside or mobile computing device and scans the patient’s barcoded wristband as one of the methods to establish positive patient identification. Next, the nurse scans the barcode on the IV medication bag and verifies that the medication matches the provider’s order displayed in the eMAR. The nurse then scans the bar code attached to the smart-pump infusion-device channel, which associates the patient and medication order with the infusion device and automatically sends the infusion parameters, including medication, dose, rate, volume to be infused, and certain other patient parameters (eg, patient weight) to the pump. The nurse uses critical thinking and employs clinical judgment prior to accepting the autoprogrammed settings and adjusts the settings when initiating a titratable dose. Once communication starts, a number of views, referred to as gadgets, are available to the health care team. The device-association gadget displays all of the devices that are associated with a given patient, that is, IV pumps/medications, ventilators, and monitors. The infusion-status gadget
displays all of the patient’s associated infusions and their status, including the amount infused and the total volume to be infused. It makes use of color coding in red, yellow, or green to show the volume remaining. This tool enhances patient safety because a low infusion volume can be easily noticed, which, in turn, decreases the likelihood of an IV medication running out before replacement is available. The color yellow indicates that there is , 1 hour of medication remaining; red signals that there is , 30 minutes of medication left in the IV. The infusion-documentation gadget is used primarily to view and document infusion data. In this view, real-time infusion and hemodynamic data populating the EHR, including infusion rate, dose, titrations, and hourly volume infused, are shown. Previously, these data needed to be entered manually into the EHR. Additional benefits of this gadget include a real-time context for changes to the infusion, titration by titration, as an additional set of hemodynamics and vital signs are included with every titration. A safety mechanism prompts the nurse to view all of the unverified data prior to signing, adding an additional layer of safety for the patient. The infusion-graphing gadget provides a real-time graphic depiction of infusion and hemodynamic data directly from the devices (Figure 1). Displayed data include patient vital signs, hemodynamics, infusion rates, and titrations, as well as the last 12 hours of signed data and 4 hours of streaming (unsigned) data.
Figure 1. Infusion graphing gadget.
Abbreviations: bpm, beats per minute; CVP, central venous pressure; DBP, diastolic blood pressure; EDT, eastern daylight time; HR, heart rate; MAP, mean arterial pressure; O2, oxygen; RR, respiratory rate; SBP, systolic blood pressure; T(axil), temperature (axillary); T(rect), temperature (rectal); UOP, urine output.
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For the pharmacy department, IVCI provides an opportunity for insight into the real-time infusion status of all continuous infusions associated with a smart infusion device across all patient care areas. Use of IVCI eliminates the need for unit-based monitoring of each individual infusion by the bedside nurse, the need for intervention by a pharmacist at the front end of the reorder process, and the distractions caused by the previous lack of transparency of the infusion production process. The end result of this integration is a transparent IV infusion administration and production process that results in improved patient safety and is mutually beneficial to nursing and pharmacy personnel alike. The pharmacy dashboard is largely a non-interactive view that displays all of the infusions currently associated with infusion pumps throughout the hospital. It is automatically sorted in order of time remaining per infusion, which enables pharmacy personnel to quickly ascertain those infusions that are top priority. The use of this work flow-management software in conjunction with the dashboard views allow for a streamlined and standardized IV infusion production process that provides insight on where each infusion is in its production cycle. The process largely decreases the interruptions to staff and the potential resulting errors, thereby promoting a safer patient environment. A tool that is useful to both nursing and pharmacy is the unit-view gadget. This is a multi-patient perspective that can be used at a central nursing station to track infusions, as well as dosages, rates, and the remaining volume for each. The unit view allows both nursing and pharmacy staff to easily see what infusions will be needed within 2 hours or less. The hovering feature provides the same level of detail, including
the status of infusions in the pharmacy process (Figure 2), thereby eliminating many needless phone calls from nursing to pharmacy to find out where patient medication is in the dispensing process, which had previously caused disruption to both nursing and pharmacy. The work-flow management software also indicates when the infusion leaves the pharmacy and changes the status to delivered.
Results
From January 15, 2012 to June 30, 2012, the drug library (ie, safety software) compliance rate was measured to be 97%. Use of the safety software is extremely important because of the great potential for harm associated with high-risk medications identified in the drug library. During the same time period, compliance with IVCI autoprogramming was determined to be 81%. The reasons for missed opportunities for autoprogramming were determined to be related to specific infusions (ie, blood products, IV flush bags, and medications that must be titrated), as well as any infusions administered during information technology downtime that require manual programming. Analysis of the software data and reports identified prevention of 782 significant near-miss medication errors during this time frame. Example of near-miss medication errors that violated the upper hard limits are provided in Table 1. These near-missed errors are reported and discussed during the Daily Safety Briefs to increase staff awareness and potentially prevent reoccurrence in the future. Table 2 presents a comparison of the number of edits made when administering infusions using the IVCI system compared with not using the IVCI system (non-IVCI). Use of the IVCI is associated with an increased rate of a ccuracy
Figure 2. Unit view gadget.
Reprinted with permission O’Shea KL. Infusion management: Working smarter, not harder. Hosp Pharm. 2013;48(suppl 3):S1–S4. www.hospital-pharmacy.com.27
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Table 1. Examples of Near-Miss Medication Errors Medication/Concentration
Upper Hard Limit
Initial Dose
Final Dose
Variance (%)
EPINEPHrine 16 mg/250 mL Vecuronium 50 mg/250 mL NOREPINEPHrine 4 mg/250 mL Midazolam 100 mg/100 mL Phenylephrine 250 mg/250 mL Amiodarone 360 mg/200 mL Midazolam 250 mg/250 mL Nitroprusside 50 mg/250 mL Iron sucrose 500 mg/275 mL Vasopressin 40 units/100 mL DOPamine 400 mg/250 mL Insulin regular 250 units/250 mL
0.5 mcg/kg/min 1.67 mcg/kg/min 1 mcg/kg/min 50 mg/h 9 mcg/kg/min 33.4 mL/h 50 mg/h 10 mcg/kg/min 69 mL/h 0.9 units/min 20 mcg/kg/min 50 units/h
110 mcg/kg/min 200 mcg/kg/min 90.6 mcg/kg/min 999 mg/h 164 mcg/kg/min 500 mL/h 500 mg/h 82 mcg/kg/min 500 mL/h 6 units/min 133 mcg/kg/min 300 units/h
0.05 mcg/kg/min 1 mcg/kg/min 0.04 mcg/kg/min 15 mg/h 5 mcg/kg/min 33.4 mL/h 50 mg/h 0.5 mcg/kg/min 60 mL/h 0.04 units/min 5 mcg/kg/min 2 units/h
10000.00 10000.00 8960.00 1898.00 1722.22 1397.01 900.00 720.00 624.64 566.67 565.00 500.00
when entering the information correctly the first time because there is no manual programming of the device. For levofloxacin, twice as many edits were made when the infusions were manually programmed (non-IVCI) compared with when the infusions were autoprogrammed (IVCI; 8.43% vs 4.2%, respectively). For vancomycin, 3 times as many edits were made when the infusions were manually programmed (non-IVCI) compared with using the IVCI method (6.85% vs 2.17%, respectively). For all other high-risk medication infusions, twice as many edits were made when the infusions were initiated by using non-IVCI compared with using IVCI (2.78% vs 1.39%). Another noteworthy advantage associated with use of IVCI compared with non-IVCI use is the number of edits made at the final confirmation screen. The confirmed and changed on final screen columns in Table 2 reflect the fact that the infusion program was changed at the last possible point of entry to the patient. The clinician approved an errant entry initially, ignoring the alert, and caught the error on the final screen prior to initiating the infusion. This sequence of events occurs more frequently for the non-IVCI infusions compared with the IVCI infusions, again resulting in more
accurate infusion programming with IVCI. Specifically for non-IVCI, 9.95% of high-risk infusions were edited at the confirmation screen compared with 2.57% with IVCI. Table 3 depicts the cost avoidance for a 1-year period associated with use of safety software and IVCI. There are significantly more edits and cost avoidance with non-IVCI than IVCI; the reason for this difference is because the use of IVCI is associated with higher programming accuracy, therefore errant rates are not entered at the outset. Analysis of the software data and reports identified prevention of 1307 near-miss medication errors during a 12-month period for the non-IVCI units and 400 significant near-miss events in the IVCI units, all of which could have caused severe—if not fatal—events had they not been intercepted by the safety software (Table 3). Assuming an estimated cost of $8,750 for each medication error,1 this finding translates into an estimated cost avoidance of $3,500,000 per year for the 3 units that used IVCI and $11,436,250 per year for the non-IVCI units. The latter numbers reflect the importance of the safety software in preventing errors associated with high-risk medication infusions that cannot be autoprogrammed using IVCI. Realistically, not all of the
Table 2. Summary of Edits and Actions Taken: IVCI vs Non-IVCI Medication
Total Programs
Sum HL Edits
Sum SL Edits
Total Edits
Total Overrides
Infusion Confirmed
Changed on Final Screena
Levofloxacin Non-IVCI CCAs (%) IVCI CCAs (%) Vancomycin NON-IVCI CCAs (%) IVCI CCAs (%) Other High-Risk Medications NON-IVCI CCAs (%) IVCI CCAs (%)
5611
452 8.43 4.20 567 5.92 1.81 447
0
0
5010
90 0.93 0.36 303
452 8.43 4.20 657 6.85 2.17 750
76 0.70 0.99 343
7973
601 11.35 4.46 2374 24.16 12.83 2885
1.65 0.76
1.12 0.62
2.78 1.39
1.27 0.86
10347
26978
24313
9.95 2.57
a Infusion was edited at the confirmation screen. Abbreviations: CCAs, clinical care area; HL, hard limit; SL, soft limit; IVCI, intravenous clinical integration.
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Table 3. Annualized Total Significant Critical Catch Edits: IVCI vs Non-IVCI Limits
Soft Limits Hard Limits Total
IVCI (n = 37 241)
Non-IVCI (n = 176 027)
Critical Catchesa
Significant Edits,b n (%)
Cost Avoidance,c $
Critical Catchesa
Significant Edits,b n (%)
Cost Avoidance,c $
270 378 648
107 (39.5) 293 (77.5) 400 (61.7)
936,250 2,563,750 3,500,000
775 1512 2287
487 (62.8) 820 (54.2) 1307 (57.2)
4,261,250 7,175,000 11,436,250
Violating an institutional-defined limit. Edit prevented significant patient harm. c $8,750 per ADR.1 Abbreviations: ADR, adverse drug reaction; IVCI, intravenous clinical integration. a
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b
errors prevented by the pump’s safety software and the use of IVCI with autoprogramming would have caused harm to the patient. A published study23 suggests that 7% of the total number of reported critical catches would have actually resulted in errors that had a negative clinical impact on patients. Methodologies used in the study to deliberately remove programming edits that were not as likely to cause harm translate into a potentially larger percentage of these edits that would have negatively impacted patients. However, a conservative approach to use the 7% cost avoidance was adopted in the absence of conclusive evidence of what impact the study’s methodologies may have had on results. Patient safety was enhanced through increasing efficiency and decreasing interruptions for both Nursing and Pharmacy. Overall, there was a 27% reduction in nursing time achieved with the use of the integrated system when starting and documenting each new infusion. Numerous steps in the process of manually programming the pumps are eliminated with the IVCI process. The number of clicks or manual programming steps on the infusion pump was reduced from an average of 27 (as high as 42) to 7 when autoprogramming a weight-based medication. Also, a time-and-motion analysis was initially done in one IVCI unit that revealed a 50% reduction in nursing time was required to titrate an existing infusion and document the action. This resulted in a nursing labor time reduction of 13 to 16 seconds per titration, which equates to 1300 nursing hours per year saved for that one unit. WellSpan is now using the IVCI process in 3 units, which should result in significantly more nursing time saved. This time savings directly results in the nurses’ focus being transferred from the task of data entry to the work of patient-centered care, and ultimately translates into a safer patient environment.
Discussion
Until recently, health care did not have the tools necessary to prospectively analyze or concurrently compare causal mechanisms for different types of adverse events.24 This 12
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situation is changing as health care begins to adopt safety methods using real-time objective data. Previously, WellSpan applied a failure modes and effects analysis (FMEA) as a method to reduce the risk of future errors; however, this technique used subjective data. WellSpan now employs a more advanced technique that models multiple combinations of events leading to a single outcome, sociotechnical probabilistic risk assessment. Sociotechnical probabilistic risk assessment can be used to identify common systemic and behavioral elements that increase or reduce the risk of serious errors. The integration of IV infusion pumps equipped with safety software with institutional information systems (eg, EHRs, bar code point-of-care, CPOE), provides real-time objective data that can be assessed using sociotechnical probabilistic risk assessment. Through IVCI, medication errors are reduced and nursing work flow simplified and improved.17 The collection of data that flows to the EHR is accurate and timely. Real-time data are available for all users of the EHR. In addition, patient care could be directed toward evidence-based standards, thereby increasing patient safety.25 Among the specific benefits of systems integration is that it relieves nursing personnel from the responsibilities surrounding reorder notification (Table 4). Fewer interruptions in work flow, for both pharmacists and nurses, helps to minimize risk of errors. Pharmacy-based monitoring decreases potential interruptions in therapy related to lack of products and, therefore, clinical risk to the patient. Research has shown that the risk of a harmful medication error is doubled when health care professionals are interrupted 4 times during a single drug administration and tripled when interrupted 6 times.26 By streamlining IV administration through technology integration, major medication errors may be diverted. There is also decreased potential for wrong drug and/or patient errors due to a stockpile of infusions in the patient care area. Additionally, use of IVCI has safeguards
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Table 4. Patient Safety Benefits of IVCI • Right patient, right drug, right route • Right device and channel – Data accuracy – Real-time data available for caregivers – Efficient: High-acuity multi-titrations • Decreased interruptions for pharmacists and nurses helps to minimize risk of errors – Decreased interruptions = Increased efficiency – Time regained can be refocused to more important clinical care activities • Pharmacy-based monitoring decreases potential interruptions in therapy related to lack of product • Decreases risk of administering discontinued medications • Decreases potential for wrong drug/patient errors associated with stockpile of infusions in patient care area • Decreases likelihood for administration of product that has outlived its stability is minimized Abbreviation: IVCI, intravenous clinical integration.
that ensure drugs do not have expired stability when they are being infused. Decreases in time spent communicating and decreased interruptions in pharmacy work flow translate into increased efficiency within the order verification and entry processes. The time regained can be refocused on more important clinical care activities. As with any new technology, several challenges were faced that were associated with the implementation of IVCI technology. Initially, it was a challenge to get the interfaces to communicate properly and the importance of having information technology involved was realized. Other challenges included times when the system must be down, thus reverting to a manual state, persuading clinicians to adopt the new technology. As more institutions integrate technology, controlled randomized trials and statistical analyses should be conducted to more accurately ascertain the impact of IVCI. An example of IVCI positively impacting patient care and nursing work flow can be seen in an emergent situation such as a code.8 Before IV integration, the nurse relied on memory and limited notes, often jotted down on paper towels or scraps of paper, to retrospectively document the infusions administered during a code. This manual process often took as much as 2 hours to complete for a single code. With IVCI, infusion data, titrations, and time stamps are captured on the pump throughout the code. The system streams information directly from the infusion pump during the code and associates all the information with patient physiologic and hemodynamic parameters from cardiac monitors. The nurse reviews the data, revises if necessary, and signs the electronic record. The synchronized data are accurately recorded automatically
in the infusion management system, thus reducing postcode documentation time to just 5 minutes.16
Conclusion
Through integration of stand-alone technologies, WellSpan has found IVCI to be a viable way to enhance not only patient safety but also staff efficiency. An integrated infusion system can help reduce medication errors, improve patient care, reduce in-facility costs, and support asset management. It can enhance continuous quality improvement efforts and help improve clinical work flow.
Acknowledgments
The authors wish to acknowledge Anne Gentry, PharmD, for her assistance with manuscript preparation and Devy Lee, BSc (Pharm), CMPP, for her assistance with data retrieval.
Conflict of Interest Statement
Donald Gerhart Jr, RPh, discloses that he serves as a consultant for Hospira, Inc and Cerner Corporation. Kristen O’Shea, MS, RN, NEA-BC, and Sharon Muller, MSN, RN, report no conflicts of interest. References
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