Nicole Wilson, RN, MSN, CPHIMS
A revolutionary invention
Beginning in the 1960s, nurses who programmed infusion pumps for their patients operated without a safety net: there were no alerts to help identify and prevent inadvertent and potentially serious IV medication errors.¹ Then, in 2002, came a revolutionary technological breakthrough that made it possible to transform standard infusion pumps into “smart” pumps—the erasable, programmable, read-only memory, or EPROM, chip. By applying this new technology to infusion pumps, it became possible to enter, modify and retain data when a pump’s power supply was switched off. For the first time, infusion pumps could be programmed with dose error reduction software (DERS), incorporating a hospital’s drug library and predetermined lower and upper drug dose limits and infusion rates—all designed to catch errors in infusion pump administration.
Smart pump adoption and benefits
Almost immediately, US hospitals saw the value of smart infusion pumps. Three years after the new pumps first launched, the American Society of Health-System Pharmacists (ASHP) reported that 32.2% of acute care hospitals had implemented them. At the time, this was a higher adoption rate than bar code medication administration (BCMA), computerized physician order entry (CPOE), and electronic health record (EHR) systems.²
Use of medication safety technologies (% of hospitals)²
Year | EHR (Complete or partial) | Inpatient CPOE w/ CDSS | BCMA | Smart infusion pumps |
2005 | 24.5% | 3.1% | 4.4% | 32.2% |
Since that time, many hospitals have reported significant benefits after implementing smart pumps. An 11-bed PICU implemented smart pumps with DERS, and was able to intercept 92 programming errors during a 17-month study period 3; and a 380-bed acute care teaching hospital saw a 33% (76 to 25) reduction of infusions with one or more errors over a 41-day study period following their smart pump implementation.⁴
Improved safety, but gaps must be addressed
In the years since incorporating DERS into infusion pumps, the software has been great at helping to improve safety with IV administrations, however there are still opportunities for improvement. For DERS to protect patients, the exact drug or fluid ordered needs to be in the drug library, allowing the nurse to make an accurate selection. When a drug isn’t in the library, it may be that pharmacy hasn’t updated it, or the library is full and there is no room to add more drugs or fluids. Nurses may be familiar with the experience of selecting a drug or fluid from the library that was “close enough” when they could not find the actual one they were trying to infuse—perhaps in the interest of being compliant. While this type of workaround might seem practical under certain circumstances, it prevents greater safety benefits from being realized. Furthermore, any incorrect programming needs to be varied enough to trigger an alert. That is to say, anything programmed within the DERS limits will not trigger an alert, but could still be in error. For example, if the Insulin is ordered to run at 5 units/hr, the DERS limits are set at 1 unit/hr – 50 units/hr, and the nurse programs 2 units/hr, a DERS alert will not trigger.
Infusion pumps disconnected from the EMR
Many in healthcare recognize that errors related to the administration of IV infusions are a high-risk problem. At the AAMI Infusion Device Summit in 2010, the FDA stated that infusion devices are the subject of more adverse incident reports than any other medical technology.⁵ This data was presented 8 years following the launch of smart pumps, so clearly there is more that healthcare organizations could be doing to advance infusion pump safety.
Following the AAMI report, ECRI evaluated a sample of infusion-related events over a two year period and found that DERS could have averted only 28% of the reported problems.⁶ And in a study that looked at 1,164 IV infusions administered using smart pumps across 10 hospitals, it was found that despite the use of DERS, 60% (699) of infusions had one or more errors including wrong drug, wrong concentration and wrong rate per dose.⁷
Some of the specific errors DERS did not catch during the 10-hospital study included.⁷
- Wrong drug selection in the pump library (n=3) e.g., Morphine selected, Hydromorphone infusing
- Mis-programmed concentration (n=3) e.g., vancomycin 1,500mg ordered, 1,750mg selected
- Mis-programmed doses/rates were the leading types of infusion errors identified (n= 26 fluids, 28 medications) e.g., Zosyn ordered to infuse at 200 mL/hr, actually infusing at 25 mL/hr.
Eight of these errors involved high-alert medications. The study determined that most errors would have been prevented if smart pump-EMR interoperability had been implemented.⁷
EMR formulary and pump library: Lack of standardization
One issue that increases the risk of infusion administration errors is the lack of alignment between a hospital’s electronic medical record (EMR) and the smart pump drug library. Imagine a nurse at the bedside, working within contrasting systems to administer an infusion. They find the drug in the DERS library, however it looks different from the EMR order (e.g. “Vancomycin 1 gram / 200 mL” vs. “Vanco 1000mg / 200 mL”). This discrepancy forces the nurse to do the conversion math manually, at the bedside, introducing further risk of error. In another example, a nurse searches for a needed drug in the drug library. Unable to find it, they choose to program the pump without DERS, or select a drug that is “close enough” in order to administer to the patient.
Protecting patients: Integrating smart pumps with a hospital’s EMR
How do we protect patients and clinicians from errors that unknowingly occur due to use of a device that isn’t fully integrated into the larger medication management ecosystem? The ECRI study which had determined that 28% of infusion errors could have been prevented with DERS also found that 75% of the reported problems could have been averted with smart pump-EMR integration.6 Both technologies—smart pumps with DERS and EMR—are needed along with other interventions, to help improve infusion safety.
Smart pump-EMR interoperability can help ensure that:
- The right drug/fluid selection is made in the drug library.
- The right concentration, dose, rate, and weight/BSA are programmed, since these parameters are sent directly from the EMR.
- All infusions programmed with smart pump integration have a matching entry in the DERS library, which leads to additional benefits such as:
- Every infusion (drugs and fluids) is entered, resulting in a more comprehensive drug library, for times when smart pump-EMR interoperability is out of scope.
- Ensures pumps have the most updated dataset; pump integration forces hospitals to change their pharmacy practices to update the datasets on the pumps more frequently resulting in complete alignment with EMR formulary.
- 100% of infusions programmed with integration are within DERS, which helps to protect titrations and rate changes after the initial programming.
- The patient ID is populated in the pump, which translates into more patient-specific data in the infusion knowledge portal.
The future of infusion safety
Enhancing DERS with smart pump-EMR interoperability
When DERS was first introduced in 2005, only 32.2% of U.S. hospitals had adopted smart pumps—a figure that has since made a significant jump to 80.5% in 2014.² During that nine year period, a lot was learned and improved upon—for our part, BD gleaned much from our experience implementing smart pumps at over 300 live sites. We’ve discovered that hospitals have started to look more closely at medical errors overall and they’re taking action to improve, as shown by the increased use of EHR, CPOE and BCMA.
Smart pump-EMR interoperability results in a more complete and accurate library, which helps ensure DERS use when manual programming of a pump is required. In healthcare, we need to redefine what DERS compliance means, continuously questioning our perception of what ‘good’ looks like by asking “What are the best practices for IV administration?” and “What metrics/evidence will help us to measure safety?”
There are some errors that smart pump interoperability cannot prevent, such as set-up issues including labeling and tubing. Additionally, there will be times when interoperability is out of scope, and DERS will need to be in place to protect manual programming. Smart pump integration is not perfect and there is room for improvement. As an industry, we are still at the beginning of this journey as evidenced by the fact that today, among the U.S. hospitals that have adopted smart pumps, approximately 300 have smart pump-EMR interoperability, or 5% of acute care hospitals.⁸,⁹
Hospitals need comprehensive solutions that include best practice polices/procedures and technologies such as CPOE, BCMA, DERS and interoperability. Smart pump-EMR interoperability is not intended to replace DERS, but rather enhance it with improved protections for the patient during infusion therapy. Together, DERS and EMR interoperability are the best solutions to safeguard end-to-end IV safety.
Use of medication safety technologies (% of hospitals)²
Year | EHR (Complete or partial) | Inpatient CPOE w/ CDSS | BCMA | Smart infusion pumps |
| 2014 | 94.1% | 80.9% | 88.4% | 80.5% |
2005 | 24.5% | 3.1% | 4.4% | 32.2% |