Data Can Identify Misprogrammed Drugs

The "Measuring Safety with Smart IV Systems" conference yielded interesting data on which drugs are the most vulnerable to dosing errors during administration at US hospitals.The focus of the conference was on how to use the data the technology produces as a blueprint for process improvement at hospitals. The recent conference was the sponsored by the ALARIS Center for Medication Safety and Clinical Improvement.

According to ALARIS, 61% of the most serious and life-threatening potential adverse drug events are related to intravenous (IV) medications. Using smart IV medication safety systems, the pharmacy can embed a customized drug library that has dosing limits as used for different patient care areas. When infusion programming differs from best practice limits, ALARIS' Guardrails Safety Software sends an alert to the caregiver, which must be addressed prior to starting the infusion. Continuous quality improvement (CQI) data, available in real time via the hospital's dedicated ALARIS server, provide a unique database within the system, allowing hospital personnel to track and evaluate averted programming errors that could have resulted in patient harm.

As a beta test site for the new wireless application of the Guardrails Safety Software, CQI data were analyzed from February to April 2004 at Sharp HealthCare in San Diego, Calif. The hospital staff found that heparin, propofol, and norepinephrine generated the greatest number of alerts when programmed in the infusion system at the point of care, according to Nancy Pratt, MSN, RN, senior vice president for clinical effectiveness. The data further outlined trends by showing how many times the programmed dose exceeded the dose limit in the system. "So for example, we learned that heparin was most frequently programmed at 1 to 1.5 times over the limit," said Pratt.

The CQI data showed personnel at the City of Hope National Medical Center in Duarte, Calif, that electrolyte replacements had a greater number of events at 7 AM, which coincided with a shift change. "We have used the data to raise staff awareness and want to look again at our next CQI data download to see if this is still a time-sensitive issue that requires a change in our practices," said Sharon Steingass, RN, professional practice leader at City of Hope.